Pre-Consultation (if you have an appointment)Inquiry Form

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[必須] = Required field

Name(Family name) Required

Name(Given name) Required

Gender Required

Male

Female

E-mail address Required

The clinic will reply to the e-mail address entered below.

[!] There have been an increasing number of cases where we have not received your email.
The domain of the e-mail address sent from our clinic is [@tokyomidtown-mc.jp].
If you have specified the domain name, please deactivate it or specify the domain to receive our clinic's e-mails.

Please enter your E-mail address again Required

Daytime contact (phone number) Required

We may call you for confirmation. Please enter a phone number which you can be reached easily during the daytime.

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Registration number (clinic ID 8 digits) Optional

Optional. Please enter your information if you know it.

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Accepting	Please submit your application within one month from 9:00-12:00/14:00-16:00 on weekdays (Monday-Friday excluding national holidays) at the facility where you receive your consultation.
CD-R Paper Results　　　　　 Proof of Payment	An issuance fee of 1,100 yen (tax included) must be paid at the counter.
Receipt (replacement)	Please be sure to bring your original receipt with you on the day of the event. If you do not have the original, a "Certificate of Payment" will be issued.