Web COVID-19 PCR test request form

・This is the Web COVID-19 PCR test request form page of Ryuoh Family Clinic. 
・必須 in red square means you have to fill out the blank to send. 
  • ・After filling in the form, please press the button of  確認画面へ (= go to confirmation page) at the bottom. 
  • ・After checking your answers on the confirmation page, please press the button of この内容で送信する (= send the contents) at the bottom. 

You need a reservation to take the PCR test by telephone in advance. Please call us before you send this form (0552762300, in Japanese only). 
If you send this form before you make a reservation, this form becomes invalid. 
ex: 10/01/2022
If you answer yes, please reconsider your travel schedule.  
If you answer yes, please reconsider your travel schedule.  
ex: Taro Ryuo

ex: 12/30/2001
ex：400-0113, 1757-1, Tomitakeshinden, Kai-shi, Yamanashi
ex：090-1234-5678
ex：Thailand
ex：2020.12.1 17:30
Please write if you want to go to Thailand, Vietnam, Taiwan, Cambodia, Laos.
Please write if you want to go to Thailand, Vietnam, Taiwan, Cambodia, Laos.
ex：JAL
Tax included.
ex：Hypertension 　
ex：2021.11.30 12:00　
ex：2021.12.1 6PM  ex: as soon as it's done. 
Overtime is weekday(Monday-Thursday)/ Saturday 6PM-9PM, Friday 1PM-6PM and Sunday/holiday 9AM-6PM. Surcharge is ¥10,000 one by one(Tax in). Please note you cannot always use overtime handling. 
If you wish, please request date and time. ex: 2022.1.1 7AM.  
Our bank account is THE YAMANASHI CHUO BANK, LTD, RYUO BRANCH, ORDINARY DEPOSIT,  664555,  KAZUHIRO NAKAZAWA.  SWIFT NUMBER is YCHBJPJT. 
If you wish, please write. We usually use printed your name.
ex: If your result is positive, we refund the fee of issuing PCR negative certificate (￥3,000). 
ファイル添付 またはここにファイルをドロップ
    Please show us the page of your face photo, name, sex, passport number and birthday. 
    ファイル添付 またはここにファイルをドロップ
      Please show us the other identification document such as Japanese health insurance card. 
      You have to retest, when there are any troubles that our PCR device can't decide the judgment.  ex: breakdown. 
      Our PCR device automatically judges the result precisely, because our PCR device is 45  PCR amplification  cycles test device. So other PCR devices possibly judge different result. In the case that although our result is positive, another result is negative, we  are not responsible for cancellation charge of your plan. 
      If you have any requests, please write.
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