Appointment Form

Please enter required information on the form below to make appointment.

■ Your Name *

■ Postal Code
-
※half-width characters　Example)240-0035

■ Address (place of treatment) *

■ Phone Number *

※half-width characters　Example)045-000-0000

■ E-mail Address

※half-width characters　Example)taro@docomo.ne.jp

■ Symptom *

※For "other", please provide the details in the comment section.

※If you have visited other clinics or hospitals for this symptom, please provide the details in the comment section.

■ Preferred date (1st choice) *
Please provide your preferred date for the treatment. Weekend and holidays cost extra charge.

Time of the day *

※If you prefer "before 9 am" or "after 6 pm", please provide your preferred time in the comment section.

■ Preferred date (2nd choice)

Time of the day *

■ Smoking *
Provide patient's smoking history. In case of smoker, please provide information whether you have smoke-free section at the residence. Please provide information whether you have smokers at your residence. (Dr. Koide is very sensitive to cigarette smoke, and may not perform treatment if there are any residue of chemicals due to smoke.)

■ Comment