About the Patient Medical Information Entrance (Inquiry) Form



Please fill in the Inquiry form under each category, Basic Information, Infectious Disease, References for Admittance, and Other Information along with details of your medical concerns.

Based on the information given, we will decide if it is possible for us to accept your inquiry, however there is a possibility that if the information provided seems that it cannot be accepted in our network, we may have to decline your inquiry at this point.

If the inquiry is decided that we should consider acceptation through our network, the network office will choose the appropriate university hospital from our university hospital cooperation list after through consideration based on your information, send the provided inquiry to them, and the informed university hospital will decide on acceptance of the patient.

After this process, the university hospital will contact you for further medical information and details before making the final decision on consultation or hospitalization.

The patient (or the patient’s attending physician) can then exchange more information between them and the hospital, allowing the patient to visit Japan and see the hospital for considering consultation or hospitalization.

Please note that if the patient is accepted in any of our network university hospitals, the medical information such as the treatment for the patient by that hospital will be shared with the network office for reference, in order to review and improve our services and network system.

Moreover, if we consider that the information is necessary for deciding the admittance of the patient, or for the actual admittance itself, we may share your basic information with the university hospitals within our network, or to a medical institution which is outside our network.

If you have thoroughly read and understood the conditions above, please proceed to the Inquiry Form to enter the patient’s information, fill in the questions and send it to the network office.

The information on this form will be sent through SSL, and we do our best to never letting your private information expose to a third party of any kind. However, please acknowledge that this system does not guarantee absolute security.