Application Form

The Comprehensive Health Examination

※ If your preferred date is within a month, please make an appointment by phone : 080-6182-0358

NAMErequired

KATAKANA

Date of Birthrequired

Genderrequired

MaleFemale

Nationalityrequired

Addressrequired

Phone Numberrequired

Email Addressrequired

Confirm Email Addressrequired

Preferred Contact Methodrequired

PhoneEmailEither

Preferred Timerequired

※ Please state your preferred time to be contacted

First Timerequired

YesNo※ Is this your first time to have the comprehensive health examination at our clinic?

Do you need an interpreter?

YesNo

Medical report in English

YesNo※ Do you need a medical report in English?
※ Japanese version will be provided if English report is not requested.

Examination Plans

Basic Plan : Monday to Friday ( AM )※ Please note that Friday is for females or married couples onlyStandard Plan : Monday to Friday ( AM )※ Please note that Friday is for females or married couples onlyBrain Imaging : Monday to Friday ( AM / PM )Perfect Plan : Monday to Friday ( AM )※ Please note that Friday is for females or married couples onlyOptional Tests
※ Any optional tests can be added to any plan or Brain Imaging to customize the plan.
Gynecological Examination : Friday ( AM only )
For available options, click here.

Your Desired Date & Time

The First Choice

Month Day Start Time 9:00 -10:30 -

The Second Choice

Month Day Start Time 9:00 -10:30 -

The Third Choice

Month Day Start Time 9:00 -10:30 -

※ IF your preferred date is within a month, Please apply by Phone.

Remarks