Page 1 of 1
Partner Referral Form
This form is for partner referrals only.
Japan Medical Navigator provides non-medical coordination and language support.
We do not provide medical advice, diagnosis, or treatment.
Company name
*
Contact person name
*
Contact email address
*
Country/Region
*
Client initials or reference name
*
Please do not enter the full name.
Initials or a reference name are sufficient.
Client nationality / current residence
*
Client consent
*
Client consent
A
Yes
B
No
/
Brief medical summary (non-diagnostic)
*
Please briefly describe the client's situation.
(Example: diagnosis name, current status, prior treatments)
Are medical records available?
*
Are medical records available?
A
Yes
B
No
C
Partially
What is the client hoping to achieve by considering Japan?
Any time constraints or urgency?
Consent confirmation
*
Consent confirmation
I confirm that the client has agreed to share their medical information for the purpose of non-medical coordination and communication with Japanese medical institutions via Japan Medical Navigator.
Submit