Sending medical examination form

At first make an appointment by phone.  (Noticed: Not available to do it on this page.)
And then send this registration form.  


Please attach the medical check up form or exam items indicated by your company or the embassy which you will apply for a visa.  Also attach your passport (photo page ) and vaccination records as needed.

Attachment①
   ↑Choose files
Attachment②
  ↑Choose files
Attachment③
  ↑Choose files

Your Personal Information
You must fill in the blanks with a red mark.

Name
Name (Same as your passport)
with large letter

Gender
Birthday (yyyy/mm/dd)
    yyyy                              mm                             dd
Age
Cell phone number
Do not use hyphen.
Ex:09035022681
Address
E-mail address
Confirm e-mail address in the second blank
Passport number
Reservation date
Reservation time
Planned departure date
Destination
Nationality
Company or school name
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