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 *
E-mail *

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? *
If you do not,you will be charged the full amount.
Preferred date1 *
Preferred time1 *
Only 10:00-12:00 on Sunday
Preferred date2
Preferred time2
Only 10:00-12:00 on Sunday
What is your problem? *

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