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【初診予約】寝屋川いずもと整形外科
※再診の方は、直接ご来院ください。
* Indicates required question
来院日(水・土の午後、日祝は休診)
*
MM
/
DD
来院時間を下記よりお選びください
*
9:00~10:00
10:00~11:00
11:00~12:00
16:00~17:00
17:00~18:00
18:00~19:00
なまえ(カタカナで入力して下さい)
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Your answer
性別
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男性
女性
生年月日
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MM
/
DD
/
YYYY
住所
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Your answer
電話番号
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Your answer
症状をお聞かせください
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