Reservations and Inquiries

Please fill in the required information below and press the "Confirm" button.
If you would like to make a reservation, we will send you a medical questionnaire beforehand.
Please note that this inquiry does not provide consultation regarding medical treatment, and replies may take a few days.
We appreciate your understanding.

Name
Phone No. ※Without hyphen
Email Address
Gender
Age
 Years
What would you like to inquire about? ※Check all that apply.

Medical departments you would like to make a reservation. ※Check all that apply.
※If you selected “Others,” please enter the details below.

How would you like to receive our documents?
【By Email】
※If you wish to change the previously entered e-mail address, please enter the designated email address.
【By Mail】
 ー 

※If the recipient is the company you work for, please enter your company's name, department, and position.
How did you hear about Haneda Clinic and the Fujita Executive Club Haneda? ※Check all that apply.
 
May we send you additional information (medical information, lectures, etc.) from Haneda Clinic Fujita Executive Club Haneda to the email address you entered?
Please refer to our Privacy Policy regarding the handling of personal information.