SEOUL ST. MARY’S HOSPITAL HEALTH PROMOTION CENTER
After fill in the application form, please send e-mail attachments
e-mail : healthcheck@cmcnu.or.kr
Tel : 82-1588-8668
Health Check-up Application
Client Information
Name
Date of Birth
Gender
□ Male
□ Female
Immigration
Status
Passport No.
Nationality
Date of
Date of
Arrival
Departure
U.S.A.
Contact No.
ROK
Home:
□ Citizenship
□Permanent
Residency
e-mail Address:
C.P:
Home:
C.P:
Address
If you have reserved a hotel, please let us know the exact information about the hotel
(in ROK)
address, date of Check-in, the reservation no. and client name.
Program Information
Program
Additional Tests
Date of
Date of Medical-
Check-up
Consultation
Medical Hx.
If you have current diagnosed diseases or been taking any medication, please let us
and
know the list of medications (e.g., anti-hypertensive, anti-diabetes, aspirin, anti-platelets,
Medication
etc) □ Yes □ No
Information
Allergy
Remark
If you may have any allergic reaction, please let us know the information about
allergens. □ Yes □ No