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ƒŒƒZƒvƒgƒ`ƒFƒbƒJ[LS*

receipt checker LS

ƒCƒ“ƒXƒg[ƒ‹”Å
ˆã—Ë@ŠÖ–¼*

medical institution name

ˆã—Ë@ŠÖ”Ô†*

medical institution number

—X•Ö”Ô†

postcode

*

address

Ž–¼*

your name

–ðE*

official position

Ž––±’S“–ŽÒ*

clerk name

“d˜b”Ô†*

tel number

FAX”Ô†

fax number

Œg‘єԆ

cellphone number

ƒ[ƒ‹ƒAƒhƒŒƒX*

e-mail address

Šm”F—pƒ[ƒ‹ƒAƒhƒŒƒX*

e-mail address

*‚Í•K{€–Ú‚Å‚·B