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Inquiry [Request for quotation]

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Inquiry [Request for quotation]
Quotation contact


    Please fill in the necessary information in the form below,Please press the confirm button.

    *This is not an order form.


    *If you are using the Daily Living Equipment Benefit System, depending on the local government, your application may not be accepted even if you purchase the product from the Kiyota Online Shop. Please be sure to check with your local government office before purchasing.

    User's nameRequired

    User addressRequired

    User's phone numberRequired

    Address to which estimates and other necessary documents should be sent

    Product delivery address

    Contact phone number

    email addressRequired

    Name of the person who entered the inquiry

    Relationship to the user

    Desired product (product number, product name, size, color, quantity)Required

    How I found out about Kiyota

    Other requests

    Handling of personal information

    Regarding the handling of personal information you have entered,Privacy PolicyPlease check the following. The information you provide will be used only for the purpose of providing information and sales activities.