Online application form

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

Name *	Last Name * First Name * Middle Name
Date of Birth *	Month Date Year
Gender *	Male Female
Nationality *
Status of Residence *
Period of Stay *
Language *	Japanese English Chinese Other 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.
Address *
Email Address *
Phone *
Type of Health Insurance *	Japanese Health Casualty Worker's Accident Overseas Insurance Own Expense
Payment Method *	Cash (JPY) Credit Card Debit Card Other
Special Requirements for Religious/Cultural Reasons (if you want us to know)
Reasons for Choosing This Hospital	Introduction of Others Articles of Newspapers and Magazines Public Medical Seminar Portal Site Emergency Response
Purpose of Your Visit	Outpatient Care Second Opinion Move in Medical Check-up Other
Your Current Hospital
Referral Letter *	Do you have an Introductory letter? Yes No
Message