US VISA MEDICAL EXAMINATION E-MAIL FORM

Please fill out every information below and press “Send e-mail” at the bottom.
After our staff confirms the e-mail, you will receive a reply and it is the confirmation of your appointment.

Thank you.

  • VISA Categoryrequired
    申請中VISAの種類
  • Appointment Date and Time(mm-dd-yyyy)requiredご予約日時
    Date:
    Time:
  • Namerequired
    氏名
    Family / Last name:
    First name:
    Name verified by PassportMilitary ID
  • Date of Birth(mm-dd-yyyy)required生年月日
  • Genderrequired
    性別
  • US Consulate/Embassyrequired
    面接場所
  • Passport numberrequired
    パスポートナンバー
  • Case Numberrequired
    ケースナンバー
    Ex. NHA (TKY)1234567890
  • Birthplace(City, Country)required出生地
    City:
    Country:
  • Prior Country of ResidencePlease list all Prior Country of Residence.required以前に住んでいた国
  • Present Country of Residence(Street, City, Zipcode)required現住所
    Street / Apt:
    City:
    Postal Code:
  • Intended US Address(Street, City, State, Zipcode)requiredアメリカで滞在予定の住所
    Street / Apt:
    City:
    State:
    Postal Code:
    We can not accept PO BOX address. Family’s address in US is acceptable
    (Parents,brothers,sisters)
  • E-mail Address(Personal or Business)required
    E-mailアドレス
  • Contact Phone Numberrequired
    連絡の取れる電話番号
    Japan Phone number:
    US Phone number(Intended)
    Country cord:1
    Area:
    Number:
  • Date of Prior Exam, if any(mm-dd-yyyy)以前にビザ健診を受診したことがある場合は、その日付を記入
  • Please scan Immunization Records or Antibody titer test results, if you have any.
    (1fire max 2MB)
    今までの予防接種の記録(母子手帳や抗体検査結果)











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