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"Everyone's Medical Seminar" participation form

"Kitano Hospital Everyone's Medical Seminar" Participation Registration Form

Please enter the following information and press the send button.*Items marked with an asterisk are required.

◆ Name of seminar attended*: January 23, 2026 (Friday) 10th Symposium in 2025: Learn about and prevent heart failure! ~Heart care you can start today~

◆ Name (first and last name)*

◆ Furigana*

◆Email address (half-width)*

◆Telephone number*

◆Age*

Your area of residence*

◆ Experience of participating in the "Everyone's Medical Seminar"*

◆ Questions you would like to ask the instructor (Free entry)

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