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Kameda Medical Center
Medical Pre-assessment Form
Please complete the information below for submission to Kameda Medical Center.
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Name
First Name
Middle Name
Last Name
Mailing Address (to receive medical documents)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
How many people?
Date of Birth
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Month
-
Day
Year
Date
Requested Date of Visit (First Choice)
Requested Second Date
Requested Third Date
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Medical Information
Gender
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Your Height
Your Weight
Current Symtoms
Please describe your medical history
Do you take treatment for diabetes?
Yes
No
Do you have a pacemaker?
Yes
No
Do you take medication?
Yes
No
If you take medication please describe medication and dosage
Other Conditions
Yes
No
If yes, please describe
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Payment Information
To complete your booking please select from the following health check programs. You can also select various health check options. Please indicate if you require accommodation and airport transportation Please note that payment is in Japanese Yen.
My Products
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3-Day Course(PET-CT + Upper-GI Endoscopy + Colonoscopy)
¥
450,000
2-Day Course(PET-CT + Upper-GI Endoscopy)
¥
400,000
2-Day Course(Upper-GI Endoscopy + Colonoscopy)
¥
200,000
1-Day Course(Upper-GI Endoscopy)
¥
100,000
Option: Thyroid gland(ultrasound / blood test)
¥
24,300
Option: Helical CT
¥
24,300
Option: Brain Image (MRA/MRI)
¥
48,600
Option: Bone density
¥
8,100
Option: Haneda Airport to Kameda Clinic (Bothway)
¥
24,000
Option: Narita Airport to Kameda Clinic (bothway)
¥
38,000
Opion: Tokyo station to Kameda Clinic (bothway)
¥
29,000
Kamogawa Grand Hotel
¥
22,300
How many nights accommodation?
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Kamogawa Grand Tower
¥
19,500
How many nights accommodation?
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Test Product
¥
10
Total
¥
0
Kameda Medical Center Location
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