Online inquiry form

If you have a question about proton therapy, please answer each of the following questions and click “Send.”
A physician will check your form and contact you within a few days.
Please understand that it may take several days for us to reply depending on the content of your inquiry.

To patients contacting us from outside of Japan:

In order to ensure that correspondence regarding your inquiry proceeds smoothly, the information you provide on the inquiry form may be shared, in accordance with appropriate procedures, with Emergency Assistance Japan, the company designated by the University of Tsukuba Hospital to provide medical coordination services to patients from overseas. You may receive a reply from Emergency Assistance Japan.

All questions marked with an asterix (*) must be answered.

*Please select an answer to the question “What condition (type of cancer) have you been diagnosed with?”

*Please select an answer to the question “Has the cancer spread to other parts of the body?”

*If you answered “yes” to the question “Has the cancer spread to other parts of the body?” please fill in which organs the cancer has spread to.

*Please select an answer to the question “Have you received radiation therapy in the past?”

*If you answered “yes” to the question “Have you received radiation therapy in the past?” please fill in which part of the body you received radiation therapy on.

*Please select an answer to the question “Are you currently receiving treatment for an illness?”

*If you answered “yes” to the question “Are you currently receiving treatment for an illness?” please fill in the name of the condition you have been diagnosed with.

*Please enter your name.

*Please enter your telephone number.

*Please enter your email address.

*Please enter a valid email address.

What condition (type of cancer) have you been diagnosed with?*
Has the cancer spread to other parts of the body?*
If yes, which organs has it spread to?
Have you received radiation therapy in the past?*
If yes, on which part of your body did you receive radiation therapy?
Are you currently receiving treatment for an illness?*
If yes, what is the name of the condition you have been diagnosed with?
Contact Information
Name*
Telephone No.*
E-mail*
Patient Information
Name
Gender
Date of Birth
Nationality (Example: Japan)
Native Language


Questions and comments
If you have any questions or comments, please enter them in this box.
  • Greetings
  • What is proton therapy?
  • For non-Japanese patients: Arranging to receive proton therapy
  • The stages of pre-treatment preparation
  • The main conditions treated with proton therapy
  • FAQ
  • Getting to the center