inquiry form

Please press the 【確認画面へ進む】 button after confiming the following contents:

Please press the 【送信する】button after confiming the following contents:

Your message has been sent. If your email arrives us by 8:00 a.m., the docto r will answer to you by 10:00 a.m. on the same day (except on closed days).
In case of arriving after 8:00 a.m., he will answer next day (as long as we are open on the day).

When you do not receive a reply from the doctor, we might not be able to send you an e-mail for some reasons. In that case, we would like you to make a phone call to us (06-6364-4177).

Have you visited here before?(必須)
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Name(必須)
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Date of birth(D/M/Y)(必須)
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E-mail address(必須)
confirmation
Phone(必須)
required
Gender
Type of question(必須)
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Question contents