Nojima clinic treatment Booking

▼please fill in the information

Name * （example: Nojima Taro）
Name in Kana * （example：のじまたろう）
Email address *
Telephone number * （example：03-6902-3270）
Fax （example：03-6902-3270）
address


▼questions about patients

what's your relationship with the patient? *
Myself Spouse Parent Son/ daughter Others

if you choose the answers except "myself", please fill the name of the patient
name ： name in Kna：

gender and age of the patient *
Male Female age

the treatment taking right now *
at home in hospital Others

whether the patient knows his/her disease?
yes no Not sure

Please give detail information of the treatment that has been taken and the treating plan and current state of the patient. *
※If the patient had taken treatment in the Nojima Clinic, please fill with the date of the first examination.
If the patient is under some treatment in hospital, please give the following information.
Name of the hospital
Location of the hospital
Name of the doctor taking charge


▼the available date for examination and other questions

Specific day and time for the examination *
※If this request can not be fulfilled, please give us full understanding
not specific Specific date
(MONTH)　(DAY)　 (TIME)

The way to contact you in order we can reach you in time to inform you the examination date *
Mail Tel FAX

other questions and inquiring contents *