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Application Form for a Patient

Please fill out the following form.
* indicates required fields

Patient Information

Name * Last Name First Name
Nationality *
First language *
Language Patient can speak * Japanese English Others
*We will require the patient to be accompanied by a translator at all times during his/her hospital visit (24 hours/days during hospitalization) if he/she cannot speak Japanese or English. Cancer Institue Hospital does NOT provide a translator, so please arrange a qualified translator on your own.
Date of birth * Year Month Date
Sex * Male Female
Religion (if you want us to know)
Address *
Address in Japan (if any)
Phone number * Home / Mobile
Phone in Japan (if any)
Can we give our name "Cancer Institute Hospital" when contacting you? *
Yes No
E-mail Address *
Do you have a referral letter? * Yes No
Name of your current hospital
What is your diagnosis?
When was your diagnosis? Year Month
What are you interested in?* Treatment at Cancer Institute Hospital
Second opinion consultation
Other( )
Have you started treatment?* Yes No
Treatment you have received (if you have already undergone any treatment). Surgery
Chemotherapy
Radiation therapy
Other( )
Insurance* Japanese Universal Insurance
Your private insurance
Self-pay
History of hospitalization outside Japan within 1 year* Yes No
If "yes", name of country

Medical Information

Please make sure you are sending the following medical information along with this application form. All documents need to be translated into either English or Japanese. If your file is too large to attach to this application form, please send it to intl.info@jfcr.or.jp.

  1. Physician's referral letter that describes the patient's medical history, current diagnosis, treatment history and future treatment plan.
  2. Diagnostic image data (e.g., MRI, PET-CT, CT, Endoscopy (upper/lower), Ultrasonography). DICOM is preferred. Please avoid sending photographs of diagnostic images because they are not very clear. We would like to receive Endoscopic images in COLOR, if possible.
  3. Exam reports (e.g., reports associated with the submitted diagnostic image data, pathology results, latest blood test results).
 

Proxy Information (If any)

If you are applying on behalf of a patient, please provide your name, contact information and relationship to the patient.

Name Last Name First Name
Sex Male Female
Relationship to the patient
Address
Address in Japan (if any)
Phone number Home / Mobile
Phone in Japan (if any)
E-mail Address

※Privacy Policy: Your personal and medical information given in this application form will be used only for purposes directly related to your medical care. Cancer Institute Hospital of Japanese Foundation for Cancer Research will NOT disclose your personal and medical information to any third party without your permission.

*I have read and agree to the Privacy Policy.

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