YesNo, I have visited before

Please bring your Japanese health insurance card. If the patient is your child, please bring his or her yellow childrens' medical treatment card.

Please bring your Japanese health insurance card once each month. If the patient is your child, please bring his or her yellow childrens' health insurance card.

Cavity treatmentCheck up and cleaningGum painOther (please type below)

MonTueWedFriSat

AMPMEither is fine



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