Appointment Request Form

Date of birth
Day:   Month:   Year:
Parent or Guardian if the patient is aged under 19 years old.

Email Address
Telephone number
 Home/mobile: -
Home address

Address in Japan
Emergency Contact

Purpose of being in Japan
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
What are your symptoms?
How long have you had these problems?
Day:   Month:   Year:
Have you had any significant past medical history?
Have you ever had any operations?
Do you have any food or medication allergies?
Are you currently under medical treatment?
Are you currently taking any medications?
Are you currently pregnant or is there a possibility of pregnancy?
Are you currently breastfeeding?
Have you ever had a blood transfusion?
Please let us know your preferred date and time for appointment.