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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*
    ◆ 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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