他の医療機関からのご紹介 | 【心臓画像クリニック飯田橋-CVIC-】心臓MRI検査・心臓ドック・画像診断のスペシャリストチーム

When referral from a medical institution
(You can download the medical information provision form)

1. Please call 03-5206-5956 to reserve the inspection date and time.
2. After the appointment date and time has been decided, please fill in the items and fax to the our hospital. (FAX: 03-5206-5958).
3. Please the second "reservation slip" give to the examinee.

If you do not have the letter of introduction,

please download and use it.

Medical information provision form / reservation slip [for handwriting]

Medical information provision form / reservation slip [for input]

If you cannot download or your department does not have an internet connection, we will send you a letter of introduction. Please feel free to contact us.

CVIC問診票（任意）

患者様がご来院後に問診票をご記入いただいています。
問診票がダウンロードできますので、時間節約のためあらかじめご記入のうえ、ご持参いただく事をおすすめします。