Please select your language: 日本語 | 中文
赤色は必須項目です。Red input form is required.红色字体的是必须填写项目

Inquiry Form

Basic Information
Name of person completing form (Contact) Relationship with patient Contact e-mail address
Name of patient (initials accepted) Date of birth Sex Religion
Male    Female
Country Language(s)

Others
Does the patient have any form of Japanese medical healthcare insurance? Yes     No
Name of Illness
In detail, what are you inquiring about?
Why is the patient seeking to be treated in Japan?
Does the patient have any past medical history/treatments?(Please provide information if you were hospitalized within the past 6 months)
The patient is currently Home Resting     Inpatient
→If you chose Inpatient, please tell us the medical institution he/she is in.
Medical Institution    
Department         
Infectious Disease
Does the patient have tuberculosis, Multiple drug resistance bacteria, or any other infectious disease? Yes     No     Unclear
→If yes, which disease? Please answer in detail.
Does the patient have any of these subjective symptoms?
A fever over 37.5 ℃/ 99.5℉ Yes     No
Cough or sputum Yes     No
Abdominal pain Yes     No
Nausea or Vomiting Yes     No
Diarrhea Yes     No
Rashes or skin eruptions Yes     No
References for Admittance
Does the patient want to be admitted to a Japanese medical facility? Yes   (    Inpatient    Outpatient   )   /    No
→If yes, does the patient have any specific hospital or doctor he/she would like to see? Yes   /    No
→If yes, medical facility
Name of doctor
Does the patient have a doctor for us to work with in her/his current country? Yes    No
→If yes, medical facility
Name of doctor
Contact information(e-mail address,etc)
Does the patient have a current address in Japan? Yes    No
→If yes, the area of the patient's house
Does the patient have any friend or family member residing in Japan to ask for support? Yes    No
→If yes, principal residence and the relationship
Other Information
Defrayer's Name
Relationship with patient
Contact e-mail address
Budget for medical expenses(Please convert and answer in yen if you can)
Type of paymentCash    Credit Card     Traveler's Check    Others
Card type       
Other Payment Methods (Please specify)   
When would you like to come to Japan? How will the patient be conveyed?
Stretcher    Wheel chair    Walk    Others  
How did you find us? (through a company, online search, etc.)
Do you have any other inquiries you would like to add?