Reservation form of Uchihashi dental clinic

This form can make your reservation one week later or more-after.
When you have urgent symptoms, please come to this clinic directly.

Family name *

First name *

Age *

Sex *

M F

E-mail *

(確認用)

We cannnot communicate with you in English by telephone. If you fill out the wrong address, you cannnot receive the notice of your reservation from us. Please be careful.

Do you have Japanese insurance card? *

Yes No

If you do not,you will be charged the full amount.

Preferred date1 *

月日

M D

Preferred time1 *

Only 10:00-12:00 on Sunday

Preferred date2

月日

M D

Preferred time2

Only 10:00-12:00 on Sunday

What is your problem? *

Oral examination
Teeth and gum cleaning
Gum pain
Toothache
False teeth
Loss of teeth filling
anything else

multiple answers allowed

Please write down here if you have something let us know before coming.

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