Name
Please enter your full name, as it appears on your foreign registration card.
Application is limited to Caucasian or Hispanic for this trial.
Please enter the date in the format yyyy/mm/dd.
cm
kg
Auto Calculated
Referral
Please enter Ref. No or name and email address of a person who introduced you to the information.
1. Current Health Condition
Please enter the date in the format yyyy/mm/dd.
2. Medical History (Past Injuries and Illnesses)
For each item above that was checked, please explain in more detail, and give your age and the treatment you received.
For example, Age 22. Fractured Right Arm
Age 20 Received Surgery
3. Allergies
Please enter the date in the format yyyy/mm/dd.
Please enter the date in the format yyyy/mm/dd.
Please enter the date in the format yyyy/mm/dd.
Please enter the date in the format yyyy/mm/dd.
Please enter the date in the format yyyy/mm/dd.
4. Others