Public intake

Remote Consultation Intake Form

Please complete this form to help AMECA review your case for a possible NCNP remote consultation. Submission does not mean a confirmed appointment.

Before You Begin

Thank you for your interest in AMECA’s International Online Second Opinion Service.

To make the application process smoother and more efficient, we have introduced an online application system for consultations in English, Japanese, and Chinese. Support in other languages may also be available; however, additional interpretation and translation fees may apply. Thank you for your understanding.

As part of this update, the total fee has been reduced from JPY 250,000 to JPY 198,000.

This fee includes:

The official NCNP Second Opinion consultation fee (JPY 110,000);
AMECA’s international coordination services;
Medical document review and preparation;
Translation support and communication with the hospital;
Administrative and processing fees.

After you submit this intake form, our team will conduct a preliminary review and discuss your case with the hospital. If the hospital determines that your case is suitable for an online second opinion, we will then issue an invoice and begin the formal consultation process.

By submitting this application, you acknowledge that you are applying for this online consultation service under the promotional fee of JPY 198,000 and agree to proceed according to the process described above.

The services described above apply to the NCNP online medical consultation program. In addition, we also provide comprehensive medical support services for patients traveling to Japan, including:

Medical Visa Guarantor Service;
Medical Interpretation during Hospital Visits and Hospitalization;
Online Support for Travel, Transportation, and Daily Living;
On-site Assistance for Transportation and Daily Living;
and other related support services.

Please note that these additional services are optional and are not included in the online consultation fee.

Please note that submitting this form does not guarantee acceptance by the hospital. Payment will only be requested after the hospital confirms that your case is suitable for an online second opinion.

We appreciate your cooperation and look forward to assisting you.

This intake has 8 sections. Most applicants can start with Personal, Contact, and Referral Purpose, then return to the medical history sections as needed.

1. Personal Information

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Basic identity and residence details.

Full name *Date of birth *Nationality *Country of residence *

Please indicate your current country of residence. This information will assist the physician in understanding your medical background and will also be used to determine the appropriate Japanese Embassy or Consulate for Medical Visa procedures, should treatment in Japan become necessary.

Time zone

2. Contact Information

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How AMECA should reach you, plus an optional emergency contact.

Email address *Preferred contact method *Phone numberWhatsApp

Emergency contact nameRelationship to patientEmergency contact phone

3. Purpose of Referral and List of Questions

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Please briefly explain why you are seeking this consultation and list the questions you would like to ask the doctor.

Requested service type *

Second opinion

Preferred department / specialty (optional)

Purpose of referral and list of questions *Main concern / reason for consultation *

4. Past Medical History and Family History

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Please provide any previous illnesses, surgeries, hospitalizations, allergies, and relevant family medical history.

Known diagnosesPast medical history and family historyAllergies / adverse reactions

5. Course of Symptoms and Treatment History

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Please describe when your symptoms began, how they have changed, and what examinations or treatments you have received.

Course of symptoms and treatment history *Current treatment statusCurrent hospital / doctorPrior examinations / treatments summary

6. Current Medications

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Please list all medicines you are currently taking, including the medicine name in your language and, if possible, in English or Japanese, together with the dosage and frequency.

Current medicationsRecent medication changes

7. Language Support

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Our online consultation service is currently available in English, Chinese, and Japanese. Support in other languages may also be available, but additional interpretation and translation fees may apply.

Language Support Notice

Thank you for your understanding.

Preferred consultation language *

8. Consent & Confirmation

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Required acknowledgements before submission.

I confirm that the information provided above is true and complete to the best of my knowledge.I understand that the online consultation is based on the medical information and documents I have submitted and does not replace an in-person medical examination.To improve the accuracy and efficiency of international medical communication, AMECA may use AI-assisted translation software during the consultation process. However, the physician’s written medical opinion shall be considered the final and official medical conclusion.I have read and accept the privacy policy.

Ready to submit your intake request.