Appointment Request

Please complete the form to request an appointment. Please note you do not have an appointment until you receive confirmation from us.

Patient Type

New Patient
Current Patient
Returning Patient

Patient card number

*Name

*Gender

Female
Male

*Age

years old

Phone number

*Email address

・Please enter your email address correctly

・Note:Incompatible with “yahoo.com” and “outlook.com” address

*Preferred Date

←Or if you are available any day, please check here.

*Preferred Time Of Day

*Do you have a Japanese Health Insurance?

Comments

（Checkups, Cleaning, Tooth pain, etc.)

*Check content

Please check the box if you have checked the above content for sending

Office hours: 9:30am-1:00pm / 2:00pm-6:30pm *Open until 4:30pm on Saturdays
Closed on Wednesdays, Sundays, and national holidays

Appointment Request

Access/Map

27-7 Motoyoyogicho, Shibuya-ku, Tokyo (1st floor) 〒151-0062

train
4 min walk from “Yoyogi-Koen” station (Exit 1) on Chiyoda subway Line
4 min walk from “Yoyogi-Hachiman” station (Exit North) on Odakyu Line
8 min walk from “Yoyogi-Uehara” station (Exit East) on Chiyoda subway Line and Odakyu Line