Clinic specializing in cancer treatment and infectious disease prevention with gene technology

First appointment

Please fill out the following form for the first appointment.
We will contact you by the next consultation day.

Appointments can also be made by phone. (+81-3-6268-0014)

*For a revisit, please use the Revisit appointment form.

First appointment form


    Applicant Required

    Patient information Required


    Age  years


    Disease name 

    Recipient of consultation Required

    Contactable telephone number Required

    ※We may contact you as necessary.

    Email address Required

    Email address(for confirmation) Required

    Preferred day and time(earliest possible)

    Preferred day and time(1st choice) Required

    Preferred day and time(2nd choice)

    Preferred day and time(3rd choice)

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