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Inquiry Type (Required)

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Contact Information (Required)

Enter your name
Telephone No.
(Example: 03-0000-0000)
Enter your telephone number
Enter your e-mail address correctly

Inquiry Details (Required)

If medical treatment is required, please provide as many details as possible, including the name of the illness, tests and treatment required, the desired medical institution, etc.

Patient Information

(If the inquiry is related to visiting Japan for medical treatment, please provide as much information as possible.)

Date of Birth
(Example: Japan)
* List the main nationality in the event of multiple nationalities.
Native Language

Visa Arrangements
Purpose of the Request

History and Background of Treatment
(This is only required if treatment is necessary)
Will you be accompanied by someone?

Personal Information

Those providing us with personal information via the [Inquiry] form available on this website are required to read and agree to the following before sending their inquiry to us.

1. Personal Information Protection Policy

Read our Personal Information Protection Policy (http://maj.emergency.co.jp/privacy) .

2. Purpose of Utilization

All personal information sent to us via the [Inquiry] form available on this website will only be used for the purpose listed below, and for no other purposes.
- For the purpose of responding to the details listed in the inquiry.

3. Safety Measures

All personal information sent to us via the [Inquiry] form available on this website is transmitted with SSL-encoded communications.
If you agree to these conditions, fill out the form and return it to us.