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(*)Full Name (in Passport)   
(*)Sex   
(*)Birth date(Age)    Year   Month   Date   Age
(*)Contact    (Phone-number)
   (E-mail)
(*)Disease Name   
Symptoms and treatment history   
(*)Wish date of appointment   Year Month Date Time
Additional questions   
?팗ending this email, it is regarded as providing personal information and the information will be used for managing patients of our clinic.