Reservation form

【Temporary measure】Prescription of the medications over the phone for the return visit.

You can use the reservation form below until 8pm the previous night
After that you can make a reservation by phone call. 03-3981-6363. +81-3-3981-6363.

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,Saturday
  11:30-13:45 / 15:00-19:30
Sunday,Holiday
  11:30-18:30(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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