Fill in the following required items, and then press the send button. This form cannot be used to make a reservation. After sending the form, contact the hospital. (029-226-6555) You can also contact us by e-mail, but it can take up to 1 to 3 days for us to check it. We appreciate your understanding.

Reservation form ※Required fields

※Full name
Passport notation
Postal code
※Telephone number
Email address
※Desired reservation date
Emergency contact information(other than the person)
Purpose of use
How to hand over the results
(If you choose mail or email,please be sure to enter your address or emailaddress)
(If you choose car,please enter the model and color in the fields below)
Car details(model,color,lisence plate)