Tsukuba Kids Clinic
new
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Name
*Please enter in English if you cannot enter in katakana.
Family name

First name

Nickname (to protect personal information)

Examination ticket number
(Please make sure there are no mistakes.)

Postal code (7 digits only)

Address (please fill in block, street number, building name, and room number)

TEL

EMail

Date of birth
year(e.g. 2006)
month(e.g. 8)
day(e.g. 10)
Sex