Please confirm your registration information below.

*Please check the following to continue with the registration.

Name*
Surname
Middle Name
Given Name
Date of Birth*
Year: Month: Day:
Age: Automatic calculation
Gender*
Address*
Postal Code 
Prefecture 
Address 
Building/Apt.# 
Phone Number *
Email Address*
Confirm Email Address*

*Please input the same email address as above.
Height (cm)*
Weight (kg)*
BMI
Automatic calculation
Nationality*
Ethnicity*

In case of Other, please specify:
Type of Visa*
(Eg. Specialist in Humanities, Student, Spousal)
Visa Expiration Date*
: Month: Day:
Medical Conditions

*Please check all that apply.

(maximum pressure 140 and over, or minimum pressure 90 and under)
*Note that if you have one of the conditions above, we may contact you to request additional information about the diagnosis, and other details.
Medical History
(Illnesses/conditions you have had, injuries that have required hospitalization or surgery etc.)
Period of onset (approximate age)
Details
Current condition
Period of onset (approximate age)
Details
Current condition
If you were introduced by someone, please provide their name.