▼Please fill in your information
Name *
Name in Kana *
Email address *
Telephone number *
（example：03-0000-0000）
fax
（example：03-0000-0000）
Address
prefectures
Hokkaido
Aomori Prefecture
Iwate Prefecture
Miyagi Prefecture
Akita Prefecture
Yamagata Prefecture
Fukushima Prefecture
Ibaraki Prefecture
Tochigi Prefecture
Gunma Prefecture
Saitama Prefecture
Chiba Prefecture
Tokyo
Kanagawa Prefecture
Niigata Prefecture
Toyama Prefecture
Ishikawa Prefecture
Fukui Prefecture
Yamanashi Prefecture
Nagano Prefecture
Gifu Prefecture
Shizuoka Prefecture
Aichi Prefecture
Mie Prefecture
Shiga Prefecture
Kyoto{
Osaka{
Hyogo Prefecture
Nara Prefecture
Wakayama Prefecture
Tottori Prefecture
Shimane Prefecture
Okayama Prefecture
Hiroshima Prefecture
Yamaguchi Prefecture
Tokushima Prefecture
Kagawa Prefecture
Ehime Prefecture
Kochi Prefecture
Fukuoka Prefecture
Saga Prefecture
Nagasaki Prefecture
Kumamoto Prefecture
Oita Prefecture
Miyazaki Prefecture
Kagoshima Prefecture
Okinawa Prefecture
▼Some questions about patients
what's your relationship with the patient? *
Myself
spouse
parents
Son/daughter
others
gender and age of the patient*
Male
Female
Age
the treatment taking right now *
Taking therapy at home
Taking therapy in the hospital
others
whether the patient knows his/her disease?*
Yes
No
Not sure about it
Please give detail information of the treatment that had been taken and the treating plan and current state of the patient.*
If the patient is under some treatment in hospital, please give the following information.
▼how to contact you and other questions you want to know
The way to contact you in order we can reach you in time to inform you the examination date *
Mail
Tel
Fax