ご予約・お問い合わせ（Appointment or Inquiry）
English follows Japanese.

＜お知らせ＞
★臨時休診　８月２日（日）～４日（火）
※木・日・祝は原則休診日ですのでお返事は翌診察日となります。

このフォームに記入して送信ボタンをクリックしてください。
48時間以内に何も返事がない場合は、再度送信か電話でお問い合わせください.
最初に、メールアドレスをE-mail欄にご記入ください。
＊欄は必ずご記入ください。

<Notice>
*We temporally close from Sunday 2nd to Tuesday 4th of August.

Our clinic is closed on Thursday, Sunday and holidays.
We will reply to you on the next weekday.

Please fill in this form and submit.

If you do not receive any reply from us within 48 hours, please inquire again or call us directly.

Firstly, please fill in your e-mail address in "メールアドレス" Email section below.

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Email *
お名前（姓名）　Name (First, middle and Last name) *
フリガナ　Tittle *
生年月日　Date of Birth *
MM
/
DD
/
YYYY
郵便番号　Postal Code *
住所/滞在先　Address/ Accommodation *
電話番号　Phone No. Available *
予約・お問い合わせの目的　Select your purpose of appointment or inquiry. *
お問い合わせの具体的内容 Describe your appointment or inquiry in detail. *
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