Full Name
Gender
Select an optionMaleFemalePrefer not to sayOther
Age
Email Address
Native Language
EnglishChineseKoreanJapaneseOther
Number of Sessions Select number1234Other
Select number56789101112131415
Wheelchair Requirement Select an optionI will bring my own wheelchair.I would like to use a wheelchair at the clinic.I do not need a wheelchair.Other
Mobility Assistance
Select an optionClinic staffFamily member / companion
Pajamas & Towels Rental
Select an optionBoth pajamas and towelsPajamas onlyTowels onlyI do not need rentals
Meal Preference During Dialysis
※ Please note:
We are unable to accommodate menu changes or provide special meals such as vegetarian, vegan, or allergy-friendly options.
Select an optionI would like a meal prepared by the clinic.I will bring my own meal.I do not need a meal.Other
Remarks
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