Jen-Ai Hospital IPC

Home > Request Form

New Patients

Regular Patients

To request a medical appointment, please enter the information below and press the "Send Appointment Request" button when you have completed the form. If you prefer to make an appointment by phone, please call the International Patient Center (0963-175-765) and we will make the appointment for you.

Patient Information

* indicates a required field

Title

Mr.

Mrs.

Ms.

Dr.

First Name *

Last Name *

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Date of Birth *

　(ex. mm/dd/yyyy)

Nationality *

Local Address *

City *

Telephone *

　(ex. 04-xxxx-xxxx or 09xx-xxx-xxx)

Fax	(ex. 04-xxxx-xxxx)

E-mail *

　(ex. xxx@xxx.xxx)

Passport Number *

ARC Number (if applicable)

Appointment Information

Have you been to Jen-Ai Hospital before? *

Yes

If yes, JAH Registration Card Number

Do you have National Health Insurance card? *

Yes

Preferred Date of Appointment *

　(ex. mm/dd/yyyy)

Reason for appointment and/or primary complaint: *

Specialty / Department you would like to be seen in:

Preferred doctor you would like to see:

Do you need an interpreter? *

Yes

If yes, what language?

General Comments:

Note:
If there is an urgency regarding your problem, please call the International Patient Center (0963-175-765) and go directly to the Emergency Room.

Please be sure to review your selections carefully before submitting this request. Jen-Ai Hospital International Patient Center looks forward to assisting you and ask that you provide as much information as possible so that we may serve you better when you come in for your appointment.