VISITOR APPLICATION FORM

☆ENGLISH☆

To request a visit, please fill out the form below and submit it to the Security Office.
・Please wear a mask and sanitize your hands in the hospital during visits.
・Visitors are required to enter the ward with their visiting permission slip holders around their necks.
Please understand that if we are unable to confirm that you are carrying your visiting permission slip, forsecurity purposes a staff member (security guard) will ask you for permission to visit.
※To prevent infection of hospitalized patients, we do not permit visitors with the following symptoms:■Fever over 37.5℃
DATE

YEAR →■Cough■Nausea/vomiting

年月MONTHDAY日■Skin rash

■Diarrhea

入館時間時
H

CHECK-IN AT THE DESK分 AMM

PM

1. INPATIENT'S NAMEHOSPITAL WARD

東 EAST WING
西 WEST WING
南 SOUTH WING

2. PURPOSE OF VISIT ① THE HOSPITALCALLED(PLEASE CIRCLE ONE)

V
I
S
I
T
O
R
①V
I
S
ITO
R
②V
I
S
ITO
R
③NAME

221②332F

4456789 F
56789 F
NMC (NEONATAL MEDICAL CENTER)

BRINGING IN PERSONALBELONGINGS③

WANTS TO SEE
THE PATIENTRELATION
SHIP

Please check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash □NONE□Have had Covid-19 infection within 10 days.

NAME

RELATION
SHIP

Please check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash □NONE□Have had Covid-19 infection within 10 days.

NAME

RELATION
SHIP

Please check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash □NONE□Have had Covid-19 infection within 10 days.
Toyohashi Municipal HospitalVISITOR APPLICATION FORM

☆ENGLISH☆

EXAMPLETo request a visit, please fill out the form below and submit it to the Security Office.
・Please wear a mask and sanitize your hands in the hospital during visits.
・Visitors are required to enter the ward with their visiting permission slip holders around their necks.
Please understand that if we are unable to confirm that you are carrying your visiting permission slip, forsecurity purposes a staff member (security guard) will ask you for permission to visit.
※To prevent infection of hospitalized patients, we do not permit visitors with the following symptoms:■Fever over 37.5℃■CoughDATE 2023 年 11MONTHYEAR →

1. INPATIENT'S NAMEHOSPITAL WARD

■Nausea/vomiting■Diarrhea

日3月DAY

1東 EAST WING
西 WEST WING
南 SOUTH WING

221(PLEASE CIRCLE ONE)

V
IS
ITO
R
②VISITO
R③NAME時30H分 AMM

PM

TOYOHASHI KENJI

2. PURPOSE OF VISIT ① THE HOSPITALCALLEDVISITO
R①入館時間
CHECK-IN AT THE DESK■Skin rash

TOYOHASHI MARIA②332F4456789F56789F
NMC (NEONATAL MEDICAL CENTER)

BRINGING IN PERSONALBELONGINGSRELATION
SHIP③WANTS TO SEE
THE PATIENT

WIFEPlease check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash ☑NONE□Have had Covid-19 infection within 10 days.

NAME

YOSHIDA ANARELATIONSHIP

DAUGHTER

Please check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash ☑NONE□Have had Covid-19 infection within 10 days.

NAME

IMAHASHI MARIORELATION
SHIP

SUPERIOR

Please check (☑) in the corresponding box.
□Fever over 37.5℃ □Cough □Nausea/vomiting □Diarrhea □Skin rash ☑NONE□Have had Covid-19 infection within 10 days.
Toyohashi Municipal Hospital