Contact information and medical release
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Reception Confirmation Sheet
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Please enter your information in the boxes below or circle the corresponding number.                    Identity check  (          )                    New ・Lost ・ Forgot
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Furigana characters(Write your name in katakana here)Furigana characters(Katakana here)Gender
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First name(Write your first name here)Last name (if changed) (Last name here)1. Male   2. Female
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Date of birth(Circle one) Showa [1926-1989] Heisei [1989-present] __________Year _____Month ______Day _________ Years Old
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Employment1. Public employee 2. Company employee 3. High School student (Grade year _______) 4. University student (Grade year _______) 5. Other student (Grade year _____) 7. Homemaker 8. Self-employed 9. Other
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AddressZIP _______ -- _____________
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Please write your apartment name or buildling number here.
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Phone numberHomeMobile or PHS
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______________ -- ____________ -- _________________________________ -- ____________ -- ___________________
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Place of work or school namePhone number (extension)
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__________ -- __________ -- ______________ ( _________)
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HeightcmWeightkg
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Blood type(Circle one)               1. A               2. O               3. B               4. AB               5. Unknown
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Would you like to receive the results of your blood testing service (liver function, cholesterol levels, etc...)?                                                             Yes                No
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Would you like to be informed if your screening tests positive for blood diseases such as hepatitis B, hepatitis C, syphilis, or HTLV-1?          Yes               No
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Should the blood center have an emergency need of your specific blood type, may we contact you for donation?                                                   Yes               No
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Previous donations (circle one)1. First time (never applied)
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2. I have donated before ( 200 mL ・ 400 mL ・ PC ・ PPP) ________ Year _______ Month ________ Day
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3. I applied, but couldn't donate                         Showa               Heisei      __________Year _____Month ______Day     -Or- ________ years ago
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Donation type                         400 mL                                   200 mL                                             Apheresis donation (platelets ・ plasma)
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