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["協会けんぽ生活習慣病予防健診申込書",{"$nulls":14},"令和5年度"]
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["事業所所在地",null,null,"〒",{"$nulls":4},"◆お支払い方法を下記より選択の上チェックをお願い致します◆"]
["事業所名"]
["ご担当者様名",{"$nulls":3},"電話番号/FAX"]
["メールアドレス",{"$nulls":7},"※窓口払いをご希望のオプションにチェックをお願いいたします。"]
["保険者番号",{"$nulls":3},"保険証記号",{"$nulls":3},"健保補助対象オプション（　                                         　）"]
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["会社保管用　　　　成績書について",null,null,"                  （ご本人様の同意が必要となります。）　　",{"$nulls":4},"その他ご要望"]
[{"$nulls":3},"※会社保管用成績書送付先が上記事業所住所と異なる場合は下記へ　　　  　　　　　　ご記入お願いいたします。"]
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[{"$nulls":3},"〒"]
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["◆下記に必要事項をご記入ください。◆"]
["各検査の年齢対象については当院のウェブサイトでご確認ください。35歳未満の方は備考欄に定期と記入してください"]
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["　　申込書はメールにて中島クリニックへ送信をお願い致します。"]
["　　MAIL：kyoukai＠nakajimaclinic.com　　TEL：03-3669-0287"]
[]
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["　　申込書はメールにて中島クリニックへ送信をお願い致します。"]
["　　MAIL：kyoukai＠nakajimaclinic.com　　TEL：03-3669-0287"]