Nishiazabu International Clinic
Patient registration
Enter the information
Name
*Please enter in English if you cannot enter in hiragana.
Family name
First name
Nickname (to protect personal information)
Patient number
(Please make sure there is no mistake)
Phone number
Mail address
Date of birth
year(e.g. 2006)
month(e.g. 8)
day(e.g. 10)
Gender
Male
Female
Egg allergy
No
Yes
Not Clear