Inquiries | Medical Access Japan

Inquiries

Inquiry Type (Required)

Inquiry related to visiting Japan for medical treatment Other inquiry

Select an inquiry type

Contact Information (Required)

Name: Enter your name
Telephone No.: (Example: 03-0000-0000); Enter your telephone number
E-mail: 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.)

Name
Gender: Male Female
Date of Birth: Year: Month: Date:
Nationality: (Example: Japan)
* List the main nationality in the event of multiple nationalities.
Native Language: Japanese English Russian Chinese
Other (list the native language)
Visa Arrangements: Required Not required Not sure
Purpose of the Request: Clinical Tests Treatment Second Opinion
Other (list the purpose of the request)
History and Background of Treatment: (This is only required if treatment is necessary)
Will you be accompanied by someone?: Yes No Not sure

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.