Reservation form

You can use the reservation form below until 8pm the previous night
After that you can make a reservation by phone call. 03-5363-0507.

Fill out the blanks and click [ Confirm ].
Appointment confirmation email will be send.
* Depend on the case, we send e-mail or call you to confim detailed contents.

① Have you ever visited our clinic?*
(*Required)

Yes No

② If you select ''yes'' on ①, please input your patient card number(there is number at left upper).

If you select ''no'' on ①, leave it blank.

Name*

(*Required)

Birth Date( MM/DD/YYYY )*

(*Required)

Sex*

(*Required)

Male  Female
Phone Number*

(*Required)

Email address*

(*Required)

Preferred date*

(*Required)

Office Hours

Weekday
  11:30-13:45 / 15:00-19:30
Saturday
  11:00-13:45 / 15:00-19:00
Sunday,Holiday
  11:00-18:00(no lunchtime.)
Closing The Office : 12/31, 1/1, 1/2, 1/3

Reception hours are different depending on the day of the week. Please check and select it.

Do you have national health insurance card issued in Japan?*

(*Required)

Yes No
Are you on trip now?*

(*Required)

Yes No
What is the purpose of your medical examination?*

(*Required)

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