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＊General urine collection＊


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General urine collection request





Address
(*)
Telephone number for report
(*)
Customer's name
(*)
Collection hope time zone
Morning　　AfternoonIt is always good.
As for the cleaning ticket, is the
preparation made?
Yes　　　No.
Does it have the cellular phone?
Yes　　　No.
Portable telephone number
A regular collection is hoped
for.
YesNo.
Selection of collection hope
Please select it while pushing theCtrlbutton when
you select the plural.
Is there a collection hope day?
It hopes.During 2‐3 day
Within one week
The number of sheets of the
cleaning ticket at hand
There is number of sheets. 　　　　 　
It doesn't understand.
Opinion impression
Please prepare it if there is no cleaning ticket. When a cleaning ticket
on hand is insufficient, all doing cannot absorb urine. Please confirm
the cleaning ticket in hand well.


(*)Please input.





　

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Please click the followingGeneral urine collection request


According to the above-mentioned content because the e-mail software used stands up


Please fill in, and transmit to our company.












* E-mail software that uses whether mail was correctly transmitted for confirmation


Please confirm the transmission history etc.







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