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The application has been completed with the following information.

Applicant information

Relationship with patientsRequired

nameRequired
furiganaRequired
genderRequired

email addressRequired
Email address (for confirmation)Required
Country of ResidenceRequired

Patient information

nameRequired
Name (in English)Required
family name
personal name
genderRequired

ageRequired
age
telephone numberRequired
－
－
email addressRequired
Email address (for confirmation)Required
messageOptional
Country of ResidenceRequired

Desired date of consultationOptional
and before and after days

and before and after days

About your medical conditionOptional

Name of diagnosis

Name of local medical institution

Name of medical department and attending physician

Department
Attending physician

Metastasis *Please fill in only for cancer patients.

Site of metastasis

Allergy: food, drug, other

History of medical history, surgery, blood transfusion
Example: 2000 Diabetes 2002 Myocardial infarction stenting surgery (2 stents)

Precautions

(If requested by the hospital, you may be asked to provide details of medications (including supplements), treatment history, etc.)

Diagnosis：

Name of local medical institution：

Department：

Attending physician：

Metastasis：

Site of metastasis：

Allergy：

History of medical history, surgery, blood transfusion：

Pledge

1.Precautions regarding health checkups, checkups, and beauty care

  • PET-CT uses radioactive materials. If you are pregnant or may be pregnant, please be sure to notify us in advance.
  • Please note that the inspection will only include the items listed in inspection item 1 of the course you have applied for.
  • Cosmetic treatments will be performed after consultation with a doctor.

2.Notes regarding medical questionnaire and test consent form

  • At medical institutions in Japan, customers are required to submit a medical questionnaire and test consent form before a medical examination or examination.
  • Depending on the content of the interview, there may be some test items that you may not be able to undergo due to medical considerations.

3.Notes from medical institutions

  • You may be required to fast and drink before the test.
  • Please refrain from strenuous exercise before the test
  • Smoking is prohibited on the premises of medical institutions.

4.Others

  • For detailed instructions, please refer to the instructions included in the welcome kit that will be sent at a later date.

5.About payment and reservation cancellation

  • This program requires advance payment. If payment is not received by the specified date, your application will be cancelled.
  • If you cancel your reservation, a cancellation fee will be charged in accordance with the terms established between the agent and our committee.

6.Handling of personal information

  • Your personal information will be strictly managed by our committee, and will be used to communicate with you and to arrange and coordinate medical institutions, concierges, translation companies, arrangement agents, etc. necessary to provide appropriate medical services. I will use it.