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*

E-mail to confirm*

Patient Information

1. Name of the patient
in Mother tongue*

in English*
2. Female / Male  

3. Date of Birth (Age)
Year*

Month*

Date*

Age*
 (y.o.)
4. Nationality・Language
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
  
E-mail: int.med.center@mt.strins.or.jp
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.