Appointment Form

Appointment Form

Please fill in the following.

Inquiry items
Name

First Name
Family Name
Date of Birth
Phone
- -
Mail
Please make sure your e-mail address is correct.
Mail(For confirmation)
Nationality
Do you have a
health insurance?
Do you have any
referral letter
from a doctor?
Please be specific
about your symptoms
and progress.
Do you prefer
inpatient or
outpatient treatment?
Is there a day or
time when it is easier
to come for
a consultaion?
Can you arrange an
interpreter by yourself?
Do you have any
other questions?
ご相談・お問い合わせ
初診予約のご案内
0848-63-8877
電話受付時間 / 8:30〜17:00
  • 受付時間 / 8:30~11:30
  • 診療時間 / 9:00~12:00
  • 診療日 / 月曜~土曜(日曜祝日 休診)