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一般社団法人 国際フロンティアメディカルサポート -International Frontier Medical Support- English
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Medical Consultation
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If you need more information about medical examination and treatment, please feel free to contact us by using the form below.

■ Medical Consultation
Contact’s information (※Required)

Name Last  
First
Middle name
Phone
E-mail address
Relation to patient Parent  Child  Relative  Friend 
Other 
Country of residence
Native language Japanese  English  Russian  Chinese 
Other 
Purpose of the request Examination  Treatment  Second opinion  Hospital referral 
Other 
How did you find this web page? Referred by family /friend   Referred by hospital 
Other 

Inquiry details
 

Patient’s information
(If the inquiry is about coming to Japan for treatment, please enter all known fields)
Name Last  
First
Middle name
Sex Male  Female
Date of Birth Year Month Day
Nationality (Example: Japan)
Native language Japanese  English  Russian  Chinese 
Other 
Medical history &
Current condition
When would you like to come to Japan year month day
How long can you stay in Japan day

About personal information

You are offering personal information in the inquiry form on our company web page. Please submit it to us after you have read and agree to the following content.

1. Privacy policy

Please see our company’s Privacy Policy

2. Purpose of use

The company use personal information you have provided to us from the Inquiry form on our company web page for the following purpose, we do not use it for other purpose.
・Reply to your inquiry
iFMS International Frontier Medical Support
IMDA 5F
1-6-5 Minatojima-minamimachi, Chuo-ku,
Kobe, 650-0047 Japan
Copyright (C)IFMS. All Rights Reserved.
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