Application form

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

Personal information

Contact person profile
Relationship with the patient*
Patient profile
year month day
First language*
Other languages*
Healthcare insurance* Are you a card holder of Japanese Public Healthcare Insurance?
About diagnosis
1 You are diagnosed with*
2 What would you like to seek consultation for? Please write details.*
3 Please discribe reason(s) why you want to be seen by medical professionals in Japan.*
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).*
5 Are you currently being hospitalized?
If "Yes", please specify the details of the medical facility.
Name of the facility
If "No", have you ever been hospitalized within last three months?
  • (When?:

Infectious diseases information

1 Are you currently a carrier of tuberculosis (TB), multidrug resistant bacteria or any other infectious diseases ?*
  • (Name of the disease:
Please answer below if you currently have following subjective symptoms.*
Fever of higher than 37.5 degrees
Cough or phlegm (mucus with pus)
Stomach pain
Nausea or vomiting
Skin rashes

Medical facility information

1 Are you seeking to be accepted by medical facility in Japan?*
If "Yes", please specify which ward you are seeking.*
2 Would you like to request a specific medical facility or a doctor?*
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?
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?
If "Yes", please answer your residential area.
5 Is your family member or friend in Japan able to cooperate assisting you?
If "Yes", please discribe its relationship.
Relationship with patient
Residential address

Payment information

Payer`s details
Relationship with patient
Approx. amount of payment limit*
Payment method*
  • Card Type
  • Detailed payment method:

Other information

Arrival at the facility
When are you seeking to be accepted?*
Transfer method of patient
How did you know about us?*
Please write other questions here if you have any.