Application form

To contact us

Use the form below to contact us by email. Someone from our hospital will reply within 3-7 working days. If it is urgent call us at 0776-23-1111. (we will not be able to speak in English)

Place of work(optional)
Work Number(optional)
Name ※
Last 
First 
Sex ※
(Home) Address (in Japan) ※ ZIP
Telephone (number) ※ May we call at this number in case we need to contact you?

Best time to call (on Friday only)
Fax (number)
E-mail ※ ※We will respond to your inquiry to the email address above.
Type of inquiry ※
Inquiry/Comments here
(※...Must input information)
 

0776-23-1111

Funabashi 7-1, Wadanaka-cho, Fukui City,
Fukui 918-8503 JAPAN.

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