Date Registration／Changes to Registration Information □ Registration □ Changes to Registration Information： 1) Change of Address □ Reissue of ID Card Family Name PLEASE ALSO SEE REVERSE 2) Change of Name First Name Hospital ID No. Maiden Name Sex 1. M Date of Birth Address mm/dd/yy 〒 2. F Nationality Age － Please provide a phone number we can reach as needed. Primary Phone Number Secondary Phone Number Tel: □ The patient in question □ Family member （Relationship: Name ） Name ） ） Tel: □ The patient in question □ Family member （Relationship: Place of employment Tel: Have you ever been to this hospital? Do you have a referral letter from another hospital? Do you have Japanese health insurance? Do you have an appointment? If “No”, please indicate the department you would like to visit today. Yes Yes Yes Yes No No No No By signing this registration form, you are considered to have understood our “Objectives of Hospital Management” and agreed to the consultation, medication and various tests to be carried out in the hospital. In addition, please refer to the information posted in the hospital concerning the treatments and surgeries which require the special submission of a consent form. Information about “Patients’ Rights” and “Patients’ Responsibilities” is also posted in the hospital. Furthermore, as this is a teaching hospital, please be aware that medical students and residents may attend all consultations and treatments. Thank you for your understanding and cooperation. ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・ For office use only ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・ 95 ・ 98 ・ 93（交） ・ 91（労） ・ 95→91（労災） 受付 説明 入力 案内 ■入力処理後、予約センターへ 〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649 Copyright © St. Luke's International Hospital All rights reserved. ） Date Registration for "Kakaritsuke-i"(Primary Care Doctor) "Kakaritsuke-i" means a primary care doctor. If you have a hospital / clinic where you usually go for consultation or for medicine when you are sick, we will register it as your "Kakaritsuke-i". Please provide the following information where possible. Name of hospital or clinic Department Name of physician Address Telephone no. For what symptoms do you usually see your doctor? (i.e., diabetes, high blood pressure, lumbago, cold, etc.) □：I agree to register the above hospital / clinic as my " Kakaritsuke-I ". ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・For office use only・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・ 患者 ID 氏名 当日受診科 SLIH-2012.2.20-Ver.5.00 〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649 Copyright © St. Luke's International Hospital All rights reserved.
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