Registration Form for Health Check-up Reservation Information

The health insurance association provides the health check-up grant only once every fiscal year.
Please note that if you have another health check-up including a mobile health check-up,
or the Toshinkyo Women’s Lifestyle Diseases Prevention check-up then, you will need to bear the full expense yourself.

 The fields marked with ※ are mandatory.

Note! If you have reserved through the website, registration of health checkup reservation information form is unnecessary.

Person with reservation

First name・Middle name・Last name

Please fill in your name which is exactly the same on your health insurance card.

Date of birth

※Dependents who are eligible for a check-up need to be 30 years or older at March 31, 2022.

Insurance card code Half-width digits

The health insurance code (保険証記号) is listed above the insured person's name.
Enter the 4-digit code of the insurance card. ※ If the code is “1”, then enter “0001”.
When the number of digits is less than 4, prepend 0 as shown above

Insurance card number Half-width digits

The health insurance number (保険証番号) is listed to the right of the health insurance code .
Enter the 5-digit number of the insurance card. ※ If the insurance card number is “12”, then enter “00012”.
When the number of digits is less than 5, prepend 0s as shown above.

Reservation information

Name of medical institution
Health check-up course
Health check-up date and time
Optional tests Optional tests (options) If you applied for any optional test then, ensure to register it. The information will be confirmed with the medical institution you made the reservation at. Please ensure that the health check-up course and options tests you reserved at the medical institution have been selected and registered. If any different courses or options have been registered, then they will be invalidated.

Contact information

〒 Postal code -
Half-width digits
City, ward, town, village
Block number, building name, room number, etc.
Mobile phone number - -
Half-width digits

※Either a Mobile phone number or Office phone number must be provided.

Office phone number - -
Half-width digits
E-mail address Half-width alphanumeric characters

※If your e-mail preferences have been set to allow or block messages from specific domains then, please adjust them so that messages from the domain “” will be accepted.

Confirm e-mail address Half-width alphanumeric characters

※A confirmation e-mail including the reservation information you registered this time will be sent to the registered email address.
※Information about the application will be shared with Rakuten Health Insurance Association for the purpose of promoting the applicant’s health.
※For the handling of personal information, please view the privacy policy.
※If any registration item is missing then, the registration process cannot be completed.
Note) If the full reservation information is not provided then, your status will be logged as [No reservation] on the system.