Appointment

Appointment Request Form

Name
Gender: Male Female Other
Date of birth: Day: Month: Year:
Parent or Guardian if the patient is aged under 19 years old.: -
Nationality
Email Address
Telephone number: Home/mobile: -
Home address
Address in Japan
Emergency Contact: -
Purpose of being in Japan: Business Study Travel Others
Date of arrival: Day: Month: Year:
Date of departure: Day: Month: Year:
The country or region you stayed prior to the arrival in Japan
Method of Payment: Credit card Cash Insurance Japanese Health Insurance
What are your symptoms?
How long have you had these problems?: Day: Month: Year:
Have you had any significant past medical history?: Yes No
Have you ever had any operations?: Yes No
Do you have any food or medication allergies?: Yes No
Are you currently under medical treatment?: Yes No
Are you currently taking any medications?: Yes No
Are you currently pregnant or is there a possibility of pregnancy?: Yes No
Are you currently breastfeeding?: Yes No
Have you ever had a blood transfusion?: Yes No
Please let us know your preferred date and time for appointment.