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厚生労働省指定臨床研修医療機関 医療法人 誠仁会 りょうき歯科クリニック

RESERVATION FORM for NEW PATIENTS RESERVATION FORM for NEW PATIENTS

Reservation from this form is【New Patients Only】.

For patients who visited us before, please call us.
Our online reservation is 【Temporary Reservation】. Contacts from our doctors make it definite.
Please note that there are cases we ask you to change the appointment time according to the congestion.

First Visit Reservation Form

-For emergency, please call us by telephone.
-A reservation on the same week or in the evening (After 6 pm) could be hard to make.
-We appreciate it if you choose date ahead For your third choice of appointment.

Symptoms/Wishes
RequiredFirst choice of appointment date and time

Second choice of appointment date and time

Third choice of appointment date and time

RequiredName
Gender
RequiredAge
years old
RequiredPhone number
RequiredE-mail address
RequiredE-mail address (For confirmation)

 
Note

Contact on the Phone

06-6781-4181

-If you haven’t got reply from us within 3 days since you contact us, there is a possibility that your inquiry wasn’t sent us for some reasons. In such case, please contact us directlyvia e-mail. If you’re in hurry, please give us a phone call.

-A reservation on the same week or in the evening (After 6 pm) could be hard to make.

-We appreciate it if you choose date ahead For your third choice of appointment.

-Our emails will be sent from info@www.ryouki4181.com .
If your email have special setting such as incoming rejection, our email may not reach you.
Please change your setting before contact us.

When you visit us, if you print out the below interview sheet and fill out, reception work will be more smooth. Please use this.