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Inquiry form

We kindly ask those who do not speak Japanese
to please visit our clinic accompanied by a medical interpreter.

Inquiry form

Please fill in the fields below and proceed to the confirmation screen.
Please click here for our clinic's information about handling personal information.

  • We do not provide medical consultation using the inquiry form.
  • We may take some time to answer. Please note that we may contact you by phone.

Please check the following content, and if there are no mistakes, press the submit button.

  • 01 Content input
  • 02 Content confirmation
  • 03 Transmission completed
Name *Required
Email Address *Required
Email Address
(for confirmation) *Required
Phone number *Required
Age *Required
Gender *Required
Number of visits
Regarding the treatment on the day
Inquiry details *Required
I agree to the privacy policy