Inquiry Form


Please complete the form below to request a free consultation. (* required fields)
We will respond to your inquiry within a few days to a week. If you don’t receive any answer from our hospital within a week, please contact us again.
In case of emergency, please contact us by phone.  

Contact Person Information

1. Name of Contact person Name
in Mother tongue*

in English*
2. Female / Male  

3. Relationship to Patient

  *Father, Mother etc.
  *Uncle, Aunt etc.
4. Contact information
Day phone*

Cell phone*


E-mail to confirm*

Patient Information

1. Name of the patient
in Mother tongue*

in English*
2. Female / Male  

3. Date of Birth (Age)



4. Nationality・Language

5. Currently address(Country)*
6. Diagnosis*
7. Chief Complain*
8. Medical Institute he/she visit*  *Hospital, Cancer Center, etc
9. Medical Department*  *Neurosurgery, Thoracic surgery etc.
10. Previous・Currently treatment

If Yes, which treatment method? Select treatment method.

11. Comment
12. Currently Patient status
13. Inquire or question
International Medical Center
Southern Tohoku General Hospital
7-115 Yatsuyamada, Koriyama-City, Fukushima-Pref. 963-8563 Japan
Copyright Southern TOHOKU Research Institute for Neuroscience. All rights Reserved.