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Dialysis Request Form

If you would like to undergo dialysis at our hospital , please fill out the necessary information in the form below and press the send button.
At that time, please download the PDF below, fill in the required information, or send a document that contains equivalent medical information as in the PDF. PDF DOWNLOAD

Title : Mr. /Ms. (Required)
 
Name : (Required)
Surname : (Required)
Nationality : (Required)
Spoken Languages : (Required)
Your Contact email : (Required)
Desired date of dialysis : [DD/MM/YYYY] (Required)
Start time : (Required)
       
Patient information file (Required)
The dialysis fee is 45,000 yen per dialysis.
Do you prefer payment by cash or credit card?: (Required)
 
Do you have travel insurance?: (Required)

How do you communicate? : (Required)



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Can you walk on your own?
If not, do you have someone to accompany you?: (Required)


How do you get to the hospital?: (Required)


Would you like meals provided during dialysis? (1,500 yen per meal): (Required)
 
Please enter any other inquires

The personal information you provide will be used only for the purpose of answering your questions.
For other handling of customer information, please refer to our privacy policy.

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