Ultimate Cancer Treatment

Proton Therapy

Southern TOHOKU Proton Therapy Center

172-7choume,Yatsuyamada,Koriyama,Fukushima 963-8563 JAPAN


 
From Doctor :For Foreign Patient and Patient who lives in foreign country  

>>Contact Person Information

1:Salutation
 Mr.  Ms.  Mrs.
2:Acad. Degree
 M.D.  D.M.D.  Ph.D.  Others
3:Name of Doctor
 in Mother tongue
 *Fill in only if you Chinese or Japanese
 in English
4:Medical Institute
 * Hospital, Cancer Center etc.
 Medical Department
 *Neurosurgery, Thoracic surgery etc.
5:Hospital Address(Country) 
6:Contact information
 Day phone
 Cell phone
 E-mail
 E-mail to confirm
7:Pourpose
 Treatment  Inquire  Second Opinion

>>Patient Information

1:Name of the patient
 in Mother tongue
 in English
2:Male・Female
 Male  Female
3:Date of Birth(Age)
 Year  Month  Date  y.o.)
4:Nationality・Language
 Nationality  Language
5:Currently address(Country) 
6:Clinical Diagnosis 
7:Pathological Diagnosis 
8:Fresh/Recurrence
 Fresh  Recurrence
9:Chief Complain 
10:Previous・Currently treatment
 Yes  No
 If Yes, which treatment method? Select treatment method.
 Surgery
 Radio Therapy
 Chemotherapy
 Others 
11:Currently Patient status
 If the patient can travel to Japan ?
 Comment
12:Inquire or question

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International Medical Center
Southern Tohoku General Hospital
7-115 Yatsuyamada, Koriyama-City, Fukushima-Pref. 963-8563 Japan

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