Phone Call Form
Kindly be advised that you need to make an appointment by phone for your first visit. In some cases, we may not be able to answer your call. Therefore please fill out the form below with your phone number and family name - we will call you back to make your first appointment as soon as possible.
(Please call us directly if urgent. If you do not receive a call by the next business day, please call us again. Please note for your first appointment it may take a few days.)

※We will call from 03-5906-5092.
What is your family name?
What is your gender?
Clear selection
Please write your phone number.
What time would you like to receive a call? (We cannot guarantee the time.)
Clear selection
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