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[null,null,null,null,null,"全国健康保険協会管掌　　健康保険【協会けんぽ】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西崎病院　　健康管理センター"]
[]
[null,"　生活習慣病予防健診申込書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話　(098)  992 - 0089"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX　 (098)  992 - 5995"]
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[]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険者番号（８桁）を記入してください"]
["問診票等ご案内の送付先",null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"      会社",null,null,null,null,null,null,null,"      本人自宅"]
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["健診結果の送付先",null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"      会社",null,null,null,null,null,null,null,"      本人自宅"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者記号を記入してください"]
["会社控え（コピー）",null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"      要",null,null,null,null,null,null,null,"      不要"]
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["健診費用のお支払い方法",null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"      後日会社請求",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    当日窓口支払"]
[]
[]
["※後日会社請求の場合",null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"ドック健診差額費用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      後日会社請求",null,null,null,null,null,null,null,null,null,null,null,null,"      当日窓口支払"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"付加健診健診差額費用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      後日会社請求",null,null,null,null,null,null,null,null,null,null,null,null,"      当日窓口支払"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"乳がん・子宮がん検診費用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      後日会社請求",null,null,null,null,null,null,null,null,null,null,null,null,"      当日窓口支払"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"：",null,"オプション検査",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      後日会社請求",null,null,null,null,null,null,null,null,null,null,null,null,"      当日窓口支払"]
[]
[]
[]
["会社名称",null,null,null,null,null,null,null,null,null,"："]
[]
[]
["振　　込　　名　　義\n（会社名称と異なる場合）",null,null,null,null,null,null,null,null,null,"："]
[]
[]
["会社所在地",null,null,null,null,null,null,null,null,null,"："]
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["電話番号",null,null,null,null,null,null,null,null,null,"："]
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["F A X番号",null,null,null,null,null,null,null,null,null,"："]
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["担当者名",null,null,null,null,null,null,null,null,null,"："]
[]
[]
[]
["フリガナ",null,null,null,null,"セイ",null,null,null,null,null,null,null,null,null,null,null,null,"メイ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男・女",null,"生年月日"]
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["氏名",null,null,null,null,"姓",null,null,null,null,null,null,null,null,null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,"昭和　平成",null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,null,"日"]
[]
[]
["住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険証",null,null,null,"番号"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先"]
[]
[]
["【希望コース】",null,null,null,null,null,null,null,null," 一般検診",null,null,null,null,null,null,null," 付加健診",null,null,null,null,null,null,null," １日ドック",null,null,null,null,null,null,null," ２日ドック",null,null,null,null,null,null,null,null," 子宮がん検診",null,null,null,null,null,null,null,null,null," 乳がん検診"]
[]
["【　第一希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第二希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第三希望日　】"]
[]
["令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[]
["【　胃部検査　】",null,null,null,null,null,null,null,null,"*　胃カメラ希望の方は、お薬確認までご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　【　カメラ経口希望の方のみ　】"]
[]
[null,null,null,"  カメラ",null,null,null,null,"(",null,null," 鼻から",null,null,null,null,null,null," から",null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,"鎮静剤",null,null,null,null,null,"：",null,null," 希望する",null,null,null,null,null,null,null,null," 希望しない"]
[]
[null,null,null,null," 歯科の麻酔（ｷｼﾛｶｲﾝ）での気分不良",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,"\n*　鎮静剤使用する場合、\n一日車の運転はしないことが条件となります。\n","    *　鎮静剤追加料金：３,３００円"]
[]
[null,null,null,null," 血液サラサラにする薬",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,"鎮静剤使用後は一日車の運転はしないことが条件となります。"]
[]
[]
[null,null,null," 胃透視（バリウム）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望オプション記入欄"]
[]
[null,null,null," 胃部検査なし"]
[]
["確定日",null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"確認事項"]
[]
[]
[]
[]
["フリガナ",null,null,null,null,"セイ",null,null,null,null,null,null,null,null,null,null,null,null,"メイ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男・女",null,"生年月日"]
[]
["氏名",null,null,null,null,"姓",null,null,null,null,null,null,null,null,null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,"昭和　平成",null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,null,"日"]
[]
[]
["住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険証",null,null,null,"番号"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先"]
[]
[]
["【希望コース】",null,null,null,null,null,null,null,null," 一般検診",null,null,null,null,null,null,null," 付加健診",null,null,null,null,null,null,null," １日ドック",null,null,null,null,null,null,null," ２日ドック",null,null,null,null,null,null,null,null," 子宮がん検診",null,null,null,null,null,null,null,null,null," 乳がん検診"]
[]
["【　第一希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第二希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第三希望日　】"]
[]
["令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[]
["【　胃部検査　】",null,null,null,null,null,null,null,null,"*　胃カメラ希望の方は、お薬確認までご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　【　カメラ経口希望の方のみ　】"]
[]
[null,null,null,"  カメラ",null,null,null,null,"(",null,null," 鼻から",null,null,null,null,null,null," から",null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,"鎮静剤",null,null,null,null,null,"：",null,null," 希望する",null,null,null,null,null,null,null,null," 希望しない"]
[]
[null,null,null,null," 歯科の麻酔（ｷｼﾛｶｲﾝ）での気分不良",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,"\n*　鎮静剤使用する場合、\n一日車の運転はしないことが条件となります。\n","    *　鎮静剤追加料金：３,３００円"]
[]
[null,null,null,null," 血液サラサラにする薬",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,"鎮静剤使用後は一日車の運転はしないことが条件となります。"]
[]
[]
[null,null,null," 胃透視（バリウム）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望オプション記入欄"]
[]
[null,null,null," 胃部検査なし"]
[]
["確定日",null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"確認事項"]