Application form｜Application｜National University Hospital Medical Cooperation Network

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Application form

Application form

Please enter necessary information in the application form. Compulsory fields are marked with *.

Personal information

Contact person profile

Name*
Relationship with the patient*
Phone*
Email*

Patient profile

Name*
D.O.B*	year month day
Age*
Gender	Male Female
Nationality*
First language*
Other languages*
Religion
Healthcare insurance*	Are you a card holder of Japanese Public Healthcare Insurance?	Yes No

About diagnosis

1	You are diagnosed with*
1

2	What would you like to seek consultation for? Please write details.*
2

3	Please discribe reason(s) why you want to be seen by medical professionals in Japan.*
3

4	Please discribe the medical history & the pretreated hisory （If you have been hospitalized within last six months, please be sure to write about it).*
4

5	Are you currently being hospitalized?
	Yes No
	If "Yes", please specify the details of the medical facility.
	Name of the facility Department
	If "No", have you ever been hospitalized within last three months?
	Yes（When?：） No

Infectious diseases information

1	Are you currently a carrier of tuberculosis (TB), multidrug resistant bacteria or any other infectious diseases ?*
	Yes（Name of the disease：） Not known No
	Please answer below if you currently have following subjective symptoms.*
	Fever of higher than 37.5 degrees	Yes	No
	Cough or phlegm (mucus with pus)	Yes	No
	Stomach pain	Yes	No
	Nausea or vomiting	Yes	No
	Diarrhea	Yes	No
	Skin rashes	Yes	No

Medical facility information

1	Are you seeking to be accepted by medical facility in Japan?*
	Yes No
	If "Yes", please specify which ward you are seeking.*
	Inpatient Outpatient

2	Would you like to request a specific medical facility or a doctor?*
	Yes No
	If "Yes", please write the facility details you want to request.*
	Name of the facility Name of the doctor

3	Are you able to obtain the cooperation from your attending doctor where you currently reside?
	Yes No
	If "Yes", please discribe the detailed information of the doctor.
	Name of the facility Name of the doctor Contacts (Email etc.)

4	Do you currently have a residential address in Japan?
	Yes No
	If "Yes", please answer your residential area.

5	Is your family member or friend in Japan able to cooperate assisting you?
	Yes No
	If "Yes", please discribe its relationship.
	Relationship with patient Residential address Phone Email

Payment information

Payer`s details

Name
Relationship with patient
Phone
Email
Approx. amount of payment limit*	JPY
Payment method*	Cash Credit card Card Type Others Detailed payment method：

Other information

Arrival at the facility

When are you seeking to be accepted?*
Transfer method of patient	Stretcher Wheelchair Walk by her/himself Others
How did you know about us?*	Website Family member Friend Media Magazines SNS Others（）
Please write other questions here if you have any.