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

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    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。
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    ご予約・お問い合わせ

    【受付時間】9:30~13:00 / 14:30~19:00

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