{"text_format":"1","workbook":"xlsx","n_sheets":1,"sheets":["C歯科･インプラントCT予約申込書 "],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":1,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"C歯科･インプラントCT予約申込書 ","index":0,"n_rows":55,"n_cols":16,"rows_kept":55,"cut":false,"hidden":false,"merged":[[49,1,49,2],[50,1,50,2],[52,11,52,15],[52,0,52,10],[46,10,46,15],[10,1,10,4],[0,0,2,15],[44,0,45,15],[5,0,5,2],[43,1,43,5],[40,0,40,1],[41,0,42,1],[15,3,15,4],[16,3,16,4],[17,3,17,4],[15,6,15,7],[16,6,16,7],[17,6,17,7],[40,2,40,6],[41,2,42,6],[40,7,40,12],[41,13,42,13],[40,14,40,15],[41,14,42,15],[3,9,3,10],[5,8,5,9],[41,7,42,12],[15,9,15,10],[16,9,16,10],[17,9,17,10],[7,10,7,15],[9,10,9,15],[11,9,11,15],[12,9,12,15]]}
["Ｃ 歯科・インプラントＣＴ　予約申込書〈ＦＡＸ専用〉"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[]
["紹介診療科",null,null,null,null,null,null,null,"紹介元"]
[]
["総合大雄会病院　口腔外科",null,null,null,null,null,null,null,"所在地"]
[]
[null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,"医師"]
[null,null,null,null,null,null,null,null,"TEL"]
["ＴＥＬ　０５８６－７２－１２１１（内線２１１２）",null,null,null,null,null,null,null,"FAX"]
[]
["★撮影希望日"]
[null,"第１希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[null,"第２希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[null,"第３希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[]
["★インプラントＣＴ撮影部位",null,null,null,"（数字をダブルクリックすると〇印がつきます）"]
[]
[null,7,6,5,4,3,2,1,1,2,3,4,5,6,7]
[]
[]
[null,7,6,5,4,3,2,1,1,2,3,4,5,6,7]
[]
["★撮影料金及び画像提供媒体（希望の数字上をダブルクリックすると〇印がつきます）"]
[null,"※ＣＤ－Ｒは上・下顎同一料金です。"]
[null,1,"ＣＤ－Ｒ（画像処理　必要）　※郵送となります。",null,null,null,null,null,null,null,"【１９，8００円（税込）】"]
[null,2,"ＣＤ－Ｒ（画像処理　不要）",null,null,null,null,null,null,null,"【１９，８００円（税込）】"]
[null,3,"オプションでフィルムも必要",null,null,null,null,null,null,null,"【　２，２００円（税込）】"]
[null,"※郵送時には送料として別途５００円（税込）が必要となります。尚、送料は予告なく改訂される場合があります。"]
["★確認事項"]
[null,"パノラマ",null,null,null,null,null,null,null,"ステント"]
[]
[null,"※ＣＴ撮影時にはパノラマが必要です。患者さまにお持ちいただいてください。（ＣＤ－Ｒでも可）"]
[null,"　 パノラマがない場合は、当院で撮影させていただきます。"]
[null,"※パノラマ撮影代",null,null,"【６，６００円（税込）】"]
["★患者さま氏名"]
[null,"(保険証の写しまたは診療録の表紙の写しでも結構です。）"]
["フリガナ",null,null,null,null,null,null,"生年月日",null,null,null,null,null,"年齢","性別"]
["患者氏名"]
[]
["〒"]
[]
[]
[null,null,null,null,null,null,null,null,null,"TEL"]
["※ご依頼いただきました内容に変更がある場合は口腔外科までお電話くださいますようお願いいたします。"]
["★受付時間　（祝日・年末年始（12月31日～1月3日）を除く）"]
[null,"月～金",null,null,"８：３０～１９：００"]
[null,"土",null,null,"８：３０～１２：３０"]
[null,"（ＦＡＸは24時間稼働 但し、受付時間外・休日着信分は翌日以降対応）"]
["送付先　　総合大雄会病院　地域医療連携室　　　\n                                                         　 　",null,null,null,null,null,null,null,null,null,null,"FAX 0586-24-9999"]
["※右記のFAX番号を確認後送信してください。"]
["※個人情報の取扱いについては慎重にお願いします。"]