NAME
E-MAIL ADDRESS
＊E-MAIL ADDRESS
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TEL
SEX
MALE
FEMALE
AGE
Consultation frequency
First Visit
Second visit (no visit over 6 month)
no visit over 2 year
visit regularly
Perferred date/first choice
Jan
Feb
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Apr
May
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Jul
Aug
Sep
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Nov
Dec
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Thr
Fri
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TIME
Perferred date/second choice
Jan
Feb
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Nov
Dec
1
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Thr
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TIME
Perferred date/third choice
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
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5
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Tue
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TIME
Person who introduce
Remark column /note
●Please filled in preferred date from first choice to third choice..
●Please understand in case of the reservation of congestion, we may ask you to visit MAIN even you expect to visit ANNEX CLINIC.
●Please fill in name of the person who introduce our clinic to you in full.
If you come from our allied clinic, please write down clinic name. (ex. St.Lukes International Hospital)
●If you want to take reservation of trial treatment, you can book between 10am to 5pm.Please write “wish trial” in Remarks column/note area.
●If you are late from reservation time, you may not able to take treatment. Without any notice of the cancellation or change the date on the day before your reservation date, we may charge you for the cancellation fee.