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Inquiry

Inquiry form

On inquiring it

  • You read "a privacy policy" on an inquiry, and please refer after an agreement.
  • An answer may take time. Please refer for the dispatch over a telephone.
Medical corporation Fukuji fortune surgery hospital TEL: 073-488-1339

About the input is careful

  1. ※The seal is a required item. Please input by all means.
  2. Please input all the katakana with full size.
  3. Please input a phone number (home or cell-phone) to get of the communication into a phone number column by all means.
  4. If input is over, please click "the contents confirmation" under the form.
  5. As contents confirmation screen opens, after confirming input contents, I click "the transmission" and am completion.
The name ※required
Example) Taro Yamada
Furigana ※required
(Katakana)
Example) Yamada Taro
Zip code
Example) 012-3456
The metropolis and districts
Municipality
Address, name
Phone number
Example) 012-345-6789 ※A cell-phone is possible
FAX number
Example) 012-345-6789
E-mail address ※required


※I reinput it for confirmation
Return address you like
Inquiry item ※required
Contents ※required
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Medical corporation Fukuji fortune surgery hospital
〒641-0021
Wakaurahigashi, Wakayama-shi, Wakayama
3-5-31
TEL. 073-445-3101
FAX. 073-445-4660
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