Please fill in requested information to the form below for examination request. We will make reservation for prior examination appointment. You can also make your reservation by phone. Please contact us during the following schedule.

Phone Reservation Mon Tue Wed Thu Fri Sat
09:30〜12:00 ×
13:00〜17:00 ×


Reservation Flow

  1. Please fill in the requested information to the following Reservation Form
  2. As soon as the information is checked, we will contact you for confirmation by phone
    (Please make sure the “Daytime Contact Phone Number” is the number we can get in touch during 10AM to 5PM during weekdays)
  3. When the date of examination is confirmed, please read the “Precaution Statement” carefully and come to our clinic.

For those who already have our clinics ID card, you only need to fill the columns marked※

ID Number
Print Name  (Full Width:FUJII TAKAHIRO)
Name  (Full Width:FUJII TAKAHIRO)
Zip Code  (Half Width:104-0061)
City  (Full Width:Chuo-Ku)
Town  (Full Width:Ginza)
Street  (Full Width:4−13−11)
Building  (Full Width:Ginza M&S Building 7F)
Home Phone Number  (Half Width:03-3544-6266)
Daytime Contact Phone Number  (Half Width:03-3544-6266)
FAX Number  (Half Width:03-3544-6267)
E-Mail Address  (Half
Date of Birth  Year  Month  Date
Age  (Half Width: 52)
Request of Examination      
Intestine Symptoms        
Upper GI Symptoms                

You will be asked to fill a questionnaire again when arriving at endoscopy treatment at the clinic
Downloading this questionnaire and bringing it with you will skip this process.

Download Questionnaire

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