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

CheckRequired	All treatments at our clinic are self-pay treatments and not covered by health insurance. For those who live overseas and are not covered by Japanese public medical insurance, or for foreigners who are covered by Japanese public medical insurance but have difficulty communicating in Japanese (including medical terminology), an additional fee of 50% of the indicated amount will be charged. Foreign residents may be subject to additional interpretation fees and other related costs.
Applicant Required	PatientOther than patient
Patient information Required	Name　 Age　 years Sex　MaleFemale Disease name
Recipient of consultation Required	PatientOther than patient
Contactable telephone number Required	※We may contact you as necessary.
Email address Required
Email address（for confirmation） Required
Preferred day and time(earliest possible)	Earliest possible day
Preferred day and time(1st choice) Required
Preferred day and time(2nd choice)
Preferred day and time(3rd choice)
Request for brochure	Please send a brochure.No need.
Inquiry or request

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Consultation hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun・Hol
10:00 - 17:00	○	○	○	○	○	○	Closed