Ashiya Mitooka ClinicAppointments(For new patients)

Ashiya Mitooka Clinic Appointments(For new patients)

Step1 Please fill out the application form below.

Step2 We will contact you by telephone to confirm appointment date as soon as we receive and check your application form.
We will decide on the examination date after consultation. (See here for further information on consultations)

Fields marked " ● " are mandatory. Please fill out completely.

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Name Required

Address Required

Telephone Number Required

Daytime Telephone Number Required

Please write a contact number where you may be available during the day such as; mobile phone numbers, company phone numbers, etc.

Fax number Optional

Email Address Required

Sex Optional

Male

Female

Date of Birth Optional

Age Required

Details of the examination and symptoms (Please fill out completely)

Preferred consultation date Required

Preferred consultation time Required

Monday/Saturday 10:15am - 12:45am

Tuesday 8:30am - 12:45am

Thursday 6:15pm - 7:45pm

Friday 5:30pm - 7:45pm

Required services Optional

Gastroscopy only

Colonoscopy only

Gastroscopy and colonoscopy

Capsule endscopy only

Gastroscopy and Capsule endscopy

Colonoscopy and Capsule endscopy

Gastroscopy, colonoscopy and Capsule endscopy

Symptoms Upper GI Required

Symptoms Upper Lower GI Required

Referrals Optional

(complete if someone introduced you to our clinic)

List of charges/pamphlets Optional

Yes

Do you have our List of Charges or Pamphlets?

Comment Optional

Please feel free to include any questions/comments/concerns above.

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