New patient registration 1/5
* items are required
Basic data
＊Family Name:
＊ Given Name:
＊sex:
select
male
female
＊Date of birth：
Y
M
D
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日本語
FamilyName:
FamilyNameKana:
GivenName:
GivenNameKana:
sex:
DOB_year:
DOB_month:
DOB_day:
自宅_郵便:
自宅_県:
自宅_市町村区:
自宅_住所続き:
自宅_電話:
携帯1:
PC_mail1:
携帯_mail1:
to: