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075-351-9200

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Request An Appointment for Travel Dialysis

Thank you for accessing our website.

Please make sure to fill in all the fields marked [Required] in the form below and click the “Confirm input” button.

Patient name
必須
Date of birth
必須
Sex
必須
Languages you can communicate in (multiple choices possible)
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Mobile phone number
必須
Email address
必須
Email address (confirm)
必須
Please enter the same email address as above.
The dialysis facility where you are receiving dialysis treatment
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必須
The telephone number of the dialysis facility where you are receiving dialysis treatment
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Have you ever visited our clinic before?
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必須
Desired date
必須

*If you would like to choose a date that is not available, please enter the desired date and time in the “Consultation details” section.

Desired time
必須

*If you would like to consult multiple times, please enter the desired date and time for the second session onwards in the "Consultation details" section.

Dialysis time
必須
How did you find out about our facility?
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Please enter your consultation details
*If you would like to use the service for multiple days, please write your desired dates and times here.
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