PATIENT REGISTRATION FORM

    Please fill out the following mail form and click the "Confirm" button to proceed to the confirmation page.
    If you do not receive a response within three business days, please contact us by phone.
    We will manage your personal information in accordance with our privacy policy

    If you are satisfied with the information entered here, click the "Send" button.

    * Mark is a required item.

    仮予約登録
    Name / なまえ
    Sex / せいべつ
    Date of birth / たんじょうび
    Phone / でんわ
    Mail address / メール
    Do you have health insurance?
    / けんこうほけんはありますか
    Nationality / くに
    Language / ことば
    What are your symptoms?
    / どうしましたか

    You understand we only take cash payments.
    / クレジットカードはつかえません
    After confirming your message, we will contact you.
    / かくにんご、ごれんらくいたします。
    Web予約
    （予約・変更）         Web予約 （予約・変更）     Webで
    お問合せ         お電話
    046-234-0880         お電話 （ご予約・お問合せ）