关于申请 About application

旅行计划 Tour Plan *	PLAN A 医疗旅游4天“北後志”出租车观光，附带DWIBS体检 Medical tourism 4 Days "Kita Shiribeshi" sightseeing course by taxi with DWIBS physical examination. PLAN B 医疗旅游5天“登别，二世古，喜乐乐”出租车观光，附带DWIBS体检 Medical tourism 5 Days "Noboribetsu,Niseko,Kiroro" sightseeing course by taxi with DWIBS physical examination. PLAN C 医疗旅游5天“洞爷湖，二世古，喜乐乐”出租车观光，附带DWIBS体检 Medical tourism 5 Days "Lake TOYA,Niseko,Kiroro" sightseeing course by taxi with DWIBS physical examination.
车辆类型 Vehicle Type *
乘客人数 Number of passenger *

申请内容：请在填写1 位受诊者的情况。

医疗机关名称 Medical Institution	済生会小樽病院
体检套餐 Medical examination course	DWIBS
开始使用日期 Operation date *
受诊者姓名 Full name *	*中国国籍的顾客请用简体字填写姓 family　name 名 personal name
受诊者姓名（拼音表示） Passport English notation	姓 family　name 名 personal name
出生年月日 Date of birth
性别 Gender *	男 male 女 female
年龄 Age *	歳
地址 Adress *
固定电话号码 Home phone
手机电话号码 Mobile phone
电子邮件 Email address *
入境日期· 出境日期 Date of entry and departure *
使用语言 Language *	汉语：普通话Mandarin Chinese 汉语：广东话 Cantonese 其他 English or other 其它

体检者现况

既往病史・现有疾病 Chronic illness	有Yes 没有No
现服用药 Currently taking medication	有Yes 没有No
心脏起搏器植入 Pacemaker	有Yes 没有No
体内有植入金属 Metal inside body	有Yes 没有No
纹身 Tattoo	有Yes 没有No
怀孕中 Pregnancy	有Yes 没有No
避孕环 IUD	有Yes 没有No

检查服尺寸

身高 Height *	cm
体重 Weight *	kg

备注 Others

以下是注意事项，请您确认：
    [1] 健康检查、检验相关注意事项
检查内容仅限于您申请的课程中列出的检查项目，请注意。
[2] 问诊表和检查同意书相关注意事项
在日本国内的医疗机构，客户在健康检查和检验前必须提交问诊表和检查同意书。
根据问诊内容，出于医疗考虑，可能会有无法进行的检查项目。
[3] 医疗机构的注意事项
如果体内有金属或纹身，可能无法接受检查。
如果在接受检查时被发现有幽闭恐惧症，检查中止时不予退款。
检查前请避免剧烈运动。
医疗机构内禁止吸烟。
[4] 其他
详细的注意事项将在后续发送的欢迎包中附带，请参阅。
[5] 支付和预约取消
本项目为全额预付款制。如在指定日期前未付款，您的申请将被取消。
关于预约取消，将根据客户与本公司之间的约定条件收取取消费用。
[6] 个人信息的处理
客户的个人信息将由本公司和JMHC 严格管理，用于与客户的联系，以及提供适当的医疗服务所需的医疗机构、礼宾服务、翻译公司、安排代理等的协调和安排。
如有任何疑问，请随时询问。

Please read the following precautions.
[1] Precautions regarding medical examinations
・Please note that only the items listed in the examination item list for the course you have applied for will be included in the examination.
[2] Precautions regarding medical questionnaires and examination consent forms
・At medical institutions in Japan, you will be required to submit a medical questionnaire and examination consent form before the medical examination.
・Depending on the contents of the examination, there may be some examination items that you cannot take due to medical considerations.
[3] Precautions from medical institutions
・If you have metal or tattoos in your body, you may not be able to take the examination.
・If claustrophobia is discovered during the examination and the examination is canceled, there will be no refund.
・Please refrain from strenuous exercise before the examination.
・Smoking is prohibited on the medical institution premises.
[4] Other
・For detailed precautions, please refer to the precautions attached to the welcome kit that will be sent to you at a later date.
[5] About payment and reservation cancellations
*All programs require advance payment. If payment is not made by the specified date, your application will be canceled.
*If you cancel your reservation, a cancellation fee will be charged in accordance with the terms and conditions agreed between you and our company.
[6] Handling of Personal Information
- Your personal information will be kept strictly managed by our company and JMHC and will be used to contact you and to make arrangements and coordination
with medical institutions, concierges, translation companies, and other agents necessary to provide you with appropriate medical services.

上述说明得到确认。The above is confirmed.

申请

关于申请 About application

PLAN A

PLAN B

PLAN C

申请内容：请在填写1 位受诊者的情况。

体检者现况

检查服尺寸

备注 Others