Ashiya Mitooka Clinic Appointments(Registered 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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Please write a contact number where you may be available during the day such as; mobile phone numbers, company phone numbers, etc.

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


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