Online application form|国際医療福祉大学

Please fill out the following form.

*indicates required fields
*IUHW Mita Hospital ask all non-Japanese Health Insurance holder to make your appointment through "Registered Medical Coordinator" in Japan. Please contact one of the medical coordinators below:
Link to Ministry of Foreign Affairs of Japan

Online application form

Last Namerequired (Only ascii characters)

First Namerequired (Only ascii characters)

Middle Name (Only ascii characters)

Date of Birth

/ / (yyyy/mm/dd)

Genderrequired

Male
Female

Nationalityrequired (Only ascii characters)

Status of Residencerequired (Only ascii characters)

Period of Stayrequired (Only ascii characters)

Languagerequired

If you speak the language other than Japanese, please bring interpreter (Japanese/your own language) for your consultation. If it is difficult for you to find the interpreter, please let us know before the first visit. We will introduce interpretation / translation firms.

Japanese
English
Chinese
Other

Other (Only ascii characters)

Addressrequired (Only ascii characters)

Email Addressrequired

入力例:foo@example.com

Phonerequired (Only ascii characters)

Type of Health Insurancerequired

Payment Method required

Cash (JPY)
Credit Card
Debit Card
Other

Other (Only ascii characters)

Special Requirements for Religious/Cultural Reasons (if you want us to know) (Only ascii characters)

Reasons for Choosing This Hospital

Purpose of Your Visit

Others

Your Current Hospital (Only ascii characters)

Referral Letterrequired

Do you have an Introductory letter?

Message