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).
ページ１
Confirm
Complete
Did you make a reservation?
*
Yes
No
If you send this form before you make a reservation, this form becomes invalid.
Reservation date
*
ex: 10/01/2022
Close contact with a person with COVID-19 (probable or confirmed) while they were ill without taking appropriate precautionary measures within the last two weeks.
*
Yes
No
If you answer yes, please reconsider your travel schedule.
Clinical symptoms such as cough, shortness of breath, chills, fatigue, muscle pain, headache, sore throat, vomiting, diarrhea, or new loss of taste or smell.
*
Yes
No
If you answer yes, please reconsider your travel schedule.
Name
*
ex: Taro Ryuo
Sex
*
Male
Female
Birthday(mm/dd/yyyy)
*
ex: 12/30/2001
Address
*
ex：400-0113, 1757-1, Tomitakeshinden, Kai-shi, Yamanashi
Phone number
*
ex：090-1234-5678
Destination
*
ex：Thailand
Boarding date and time
*
ex：2020.12.1 17:30
Expected entry date（Local date and time）
Please write if you want to go to Thailand, Vietnam, Taiwan, Cambodia, Laos.
Address of stay（in English）
Please write if you want to go to Thailand, Vietnam, Taiwan, Cambodia, Laos.
Airline
*
ex：JAL
Request of certificate
*
PCR test ¥27,000
PCR negative certificate ￥3,000
Health certificate ￥3,000
Tax included.
Sampling site
Nasopharynx
Saliva
Past medical history
*
ex：Hypertension
Request of the test date and time
*
ex：2021.11.30 12:00
Request of the certificate receipt date and time
*
ex：2021.12.1 6PM ex: as soon as it's done.
Request of overtime handling
*
Yes
No
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.
Request of overtime handling date and time
If you wish, please request date and time.
ex: 2022.1.1 7AM.
Payment
*
Cash
Credit card
PayPay
LINEPay
Bank transfer
Our bank account is
THE YAMANASHI CHUO BANK, LTD, RYUO BRANCH, ORDINARY DEPOSIT, 664555, KAZUHIRO NAKAZAWA. SWIFT NUMBER is YCHBJPJT.
Address of receipt
If you wish, please write.
We usually use printed your name.
Bank account to refund
*
ex: If your result is positive, we refund the fee of issuing PCR negative certificate (￥3,000).
E-mail address
Upload the image of your passport
*
Add files
Drop down or upload files here
Please show us the page of your face photo, name, sex, passport number and birthday.
Upload the image of Japanese health insurance card
Add files
Drop down or upload files here
Please show us the other identification document such as Japanese health insurance card.
Agreement of retest
*
Agree
You have to retest, when there are any troubles that our PCR device can't decide the judgment. ex: breakdown.
Agreement of the judgment
*
Agree
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.
Free description
If you have any requests, please write.
Back
Confirm
This page is secured by SSL/TLS
Save for later
Save for later
Restore saved data
Restore