Regarding application for Temporary Dialysis

Reservations are accepted by phone or email.

Please bring any medications you may need before, during, or after dialysis.

+81-06-6357-5585

Temporary Dialysis application form

requiredName
requiredE-mail
requiredNationality
requiredAddress
requiredTelephone
requiredDate of birth
Age
requiredSex
requiredPreferred Date and Time of Visit
First Choice
Second Choice
requiredMedical visit history to this hospital
Hospital name
Hospital Telephone
requiredPurpose
requiredADL
Care giver

If you require extra nursing care, please let us know.

Allergy

If you have any known allergies, please list them here.

Shunt limb
Message
requiredAbout privacy policy

Please read our privacy policy below: You must agree to the privacy policy before submitting the form

Privacy policy (I assume this will go over the box containing the privacy policy?)