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Contact method

After you sent an email, it may take us time to reply. Please be patient.
Mandatory
Name
Family name
First name
Contact name
Contact address, etc.

E. g.: hotel name, room number, address of company or organization
MandatoryEmail address


Contact method
Contact phone number
Please choose

After choosing international or domestic number, please fill in the blank starting with the country number in case of international, and type in half-width characters.
Relation to the patient

Please write from your point of view.
Patient
Family name
First name
Sex
Age of the patient
Name of the country of the case



Region (state, city, etc.)


Local date of the accident/incident
Day Month Year

Local time of the accident/incident
Hours Minutes

症状

Please choose from sickness, injury, accident, and other.
Name of the sickness, etc.

Please write about your problem, name of the sickness, injury, symptoms, medical treatment, etc.
Local place of contact

Please choose from hospital, place of accommodation, other.
Name of local place of contact
Local contact method

Please choose from mobile or landline phone.
Local contact phone number

After choosing international or domestic number, please fill in the blank starting with the country number in case of international, and type in half-width characters.
Region of the place of return
Place of admission upon returning


Please choose from undecided, considering, willing to get a referral from the Center, other.
Your expectations concerning the place of admittance

Please write about your expectations/requests of the hospital for admission, etc.
International travel insurance, etc.

Please choose from not enrolled, enrolled, other.
Information about international travel insurance, etc.

Please write the information about your international insurance, etc.
MandatorySending the email