Appointment requests

Please read the following instructions before you make online reservation.

This form alone does not confirm the reservation.Your precise reservation time will be informed to you by our receptionist on the next business day by telephone. Your appointment will be confirmed when you receive confirmation by phone.
Your reservation can be made from 3 days to one month ahead of your telephone call.
In case you have no contact by our receptionist, please give us a call.
Change of the reservation date/time, or the cancellation is accepted only by telephone.
Choose the date/time you wish to reserve. The Clinic is closed on Sunday, National Holidays
If you do not receive a reply by the end of the next business day, please check to see if it has been sorted into your “junk mail folder” or “trash box.

Registration form

Is this your first visit?
Compulsory Input

Yes No

Choose the date / time you wish to reserve. When you click the column, the calendar will appear. Then, choose the date and click.Or, you can just type the date in the blank box.

1st choice date
Compulsory Input ※The Clinic is closed on Sunday, National Holidays

1st choice time
Compulsory Input

2nd choice date
Optional ※The Clinic is closed on Sunday, National Holidays

2nd choice time
Optional

Choose the plan
Optional
Choose the plan from the following options. (multiple choice is available)

Caries Implant Whitening Cleaning Periodontal disease Aesthetic treatment Regular medical examination and maintenance Continuation of treatment Treatment consultation / others

Name
Compulsory Input

Phone Number
Compulsory Input

TEL TIME
Optional
Reception at 9:30～12:30/14:00～17:30 We will phone you from the clinic to confirm the appointment.

Weekday： o'clock 〜 o'clock・ o'clock 〜 o'clock

Saturday： o'clock 〜 o'clock・ o'clock 〜 o'clock

e-mail
Optional

inquiry data entry
Optional

e-mail newsletter registration
Compulsory Input
Would you like to receive updated information and a newsletter from our clinic?

Yes No

Please proceed to the Confirmation Page, on the consent of our "Privacy Policy"

*Your appointment has not yet been confirmed.Our staff will call you within the next business day.

For first visitors

①Regarding to appointment time

If you are late more than 5minutes, we may ask for rescheduling.Please arrive here on time for appointment.

②Regarding to payment

We basically take cash for the treatment covered by Japanese health Insurance.If you prefer to pay by credit card, the following fees will be charged.

[Billed amount: Fee]
1,000 yen or less: 100 yen
1,001 yen to 5,000 yen: 300 yen
5,001 yen to 10,000 yen: 500 yen
10,001 yen or more: 5% of the billed amount

③Regarding to any documents for claiming

There will be charge for any documents you bring for us to fill in and it takes approximately 1week.Please let us know in advance if you have any documents with you.

④Regarding to receipt in English

Please let us know in advance if you wish to have a receipt in English.Please note that we only issue one (Japanese or English) and can not be reissued.

Inquiry by the telephone is here

For the reservations of Dental Check-up, Implant, Orthodontics, Ceramic restorations etc, please call us during business hours.

03-5413-7912

Office hours
Monday-Saturday 9:30～12:30 / 14:00～17:30
Closed on Sundays and Holidays

Office hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun／ Holidays
9:30 ～ 12:30	〇	〇	〇	〇	〇	〇	×
14:00 ～ 17:30	〇	〇	〇	〇	〇	〇	×

Tokyo Midtown Dental Clinic

Appointment requests