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:
    • Date of Birth(mm-dd-yyyy)required生年月日
    • Passport numberrequired
      パスポートナンバー
    • Genderrequired
      性別
    • US Consulate/Embassyrequired
      面接場所
    • 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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