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    • Name
    • E-mail
    • Tel

    • Message

Please fill in the blank to desire treatment by all means as follows. When there is not entry,
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    • Address/ TEL/Email
    • What did you hurt it?
    • When do you have pain ?
    • Doctor diagnosis contents
    • Medical history/Past history
    • Where do you have pain?
    • How does it pain worse?
    • The clinic/hospital history