Basic Information

English Name(務必同護照名)

Mobile

Birthday(Y/M/D)

Age

Gender Malefemale

Expecting dialysis location

Hotel or Place you stay [text* text-387 autocomplete:name akismet:author "if not sure, please write "not sure" "]

Accompanying Person noFamilyFriendOther

Language Ability of Dialysis Patients or Accompanying Person
JapaneseGreatA littleNot at all
EnglishGreatA littleNot at all

Length of Treatment(Hour)43.5Other

Frequency of dialysis treatment during this trip12Other

HepatitisNoneHepatitis BHepatitis CBoth Hepatitis B&C

Expected date and shift of dialysis
Date

1st Time PriorityMorningAfternoonNight

2nd Time PriorityMorningAfternoonNight

第二次透析 (若僅需一次透析，以下可免填)

Expected date and shift of dialysis
Date

1st Time Priority MorningAfternoonNight

2nd Time Priority MorningAfternoonNight

Expecting dialysis location

Other Information

Years of Dialysis(年/月)

Hotel or Place you stay

Typebusiness tripIndividual TravelerTourist Group

Depart date

Return date

Other Contact Information

(為避免重要事項聯絡不到本人，請務必留下第二位聯絡人)

Name of Other Contact

Mobile of Other Contact

與腎友關係

Main Contact Person腎友本人其他聯絡人

Email of Main Person

LINE ID(旅遊目的地可連絡)

LINE ID Owner 腎友本人其他陪同人員

Other Requirement (option)

Δ