Clinic hours: 11:00-20:00
03-6381-7258
requiredidentity
requiredfurigana
requiredEmail Address
anypostal code
mail
requiredaddress (e.g. of house)
requiredDate of birth (Year Month Day)
requiredPhone number
anyPreferred consultation date and time It would be very helpful if you could give us about 3 items.
first choice
time of -11 o'clock12 o'clock1:00 p.m.14:003:00 p.m.16:005:00 p.m.18 o'clock19:00one percent (one-tenth of a wari)00 minutes15 min.30 min.45 min.
second choice
third choice
requiredDiagnosis and Treatment
remote medical examinationvisit to a hospital, temple, school, etc.
*Please select a payment method only for remote medical services. Credit card payment (Visa and Master only)bank transferCOD
requiredWould you prefer ED (erectile dysfunction) treatment or AGA (alopecia) treatment?
EDAGAboth
requiredHow did you hear about us? (Multiple answers allowed)
Google (WWW search engine)YAHOOOther MediabillboardBuilding SignageIntroduction by an acquaintanceOther
If other, please fill in
Please enter coupon code if you have one
Δ
EN 
ZH_HK 
JA