Patient

Contact

Please be sure to enter your correct e-mail address, as we will only respond to you by e-mail.
Please note that we may not be able to respond to all the inquiries we receive.
Please understand that it may take a few days for us to respond to your inquiry.

The personal information you provide in this form will be used only for the purpose of responding to your inquiry.
We will not provide your personal information to any third party (except for our subcontractors) without your consent.

    Patient's information form

    RequiredFull name

    RequiredGender

    RequiredDate of birth

    RequiredZip code

    RequiredCountry

    RequiredPrefectures

    RequiredCity

    RequiredAddress

    RequiredE-mail

    RequiredPhone number

    RequiredEmergency
    contact
    information

    Full namePhone numberE-mail

    Information about the disease

    RequiredDiagnosis


    Please write your diagnosis and describe your main symptom in the box below.

    RequiredReferral hospital

    RequiredDepartment of
    referral hospital

    RequiredReferral letter

    RequiredCT image

    RequiredMRI image

    RequiredPET image

    NOTE: Data above must contain images of the lesion or treatment site.

    RequiredPathology report

    RequiredHave you contacted
    guarantors
    (travel agencies) yet?

    Native language

    Interpreter request

    Occupation

    Special requirements
    (eg. dietary or
    religious restrictions)

    Remarks

    We would appreciate your informing us of any questions or requests you may have.

    Privacy Policy

    We are committed to providing reliable medical care to our patients. We believe that it is very important to properly protect and manage "patients' personal information. To this end, we have established the following privacy policy and will make every effort to ensure its implementation.

    Collection of Personal Information

    When we collect patients' personal information, we will do so within the scope of medical treatment, nursing care, and patient care. When using personal information for other purposes, we will inform you of the purpose of use and obtain your consent in advance. The same applies when personal information is required on our website.

    Use and Provision of Personal Information

    The clinic will not use patients' personal information beyond the scope of the original purpose of use, except in the following cases

    • With the patient's consent

    • When used after processing (*1) in a manner that does not identify or specify individuals

    • When required by law or regulation to provide the information

    We will not provide such information to a third party (*2) without the patient's permission, except as required by law.