Inquiry form

Please give us a call at 03-6721-6239 regarding appointment request from 8:30 to 17:00. (*Except for Saturdays, Sundays, National Holidays in Japan)

*Mandatory fields are marked with an asterisk.

Your Full Name *
E-mail Address *
Phone Number *
Your Date of Birth *
Date

Month

Year
Hospital ID number
(if you already have one)
Are you a resident card holder in Japan? *

Yes

No

×
Japanese Residence Card

Japanese Residence Card image

reference：
https://www.moj.go.jp/isa/applications/procedures/whatzairyu_00001.html

What are your symptoms? *

We will respond to you within one business day.
For information about management of personal information, please refer to our Privacy Policy.

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