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["ＦＡＸ番号　　024-923-617８",{"$nulls":5},"お申込みの際は、こちらの用紙にご　記入の上、ＦＡＸにてご連絡ください"]
["桑野協立病院　健康管理部　　行"]
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["被保険者証の種類",null,"例：○○健康保険組合　全国健康保険協会（協会けんぽ○○支部）など"]
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["契約健診機関",null,"　　　東振協（東京都総合組合　保健施設振興協会）　　　その他（　　　　　）　　　無し"]
["連絡先住所",null,"〒"]
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["電話・ＦＡＸ",null,"電話",null,null,null,"ＦＡＸ"]
["結果送付先住所",null,"〒",null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　＊同じ時は同上"]
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["請求書送付先住所",null,"〒"]
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["健診料金",null,"　　　　　　　窓口払い　・　会社請求　　　　＊受診者負担分がある場合は、左記に○印"]
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["*尚、予約日につきましては極力変更無いようご準備をお願いいたします。都合により変更が生じた場合"]
["　には準備の都合上、『予約日の２週間以降での再予約』となります。予めご了解をお願いいたします。"]
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