Appointment Request Form

Important Information

Before proceeding, please review our policies regarding Medical Scope, Language Support, Payment Methods, and our Cancellation Policy below.

Medical Scope

We do not provide diagnosis/treatment for ongoing conditions, second opinions, prescriptions, or emergency care.

Language Support

To ensure clinical accuracy, a professional medical interpreter arranged by Keio is required, and interpreter fees will apply. Personal interpreters (family or friends) are not permitted.

Payment Method

Payment must be made in full on the day of your visit via Cash or Major Credit Cards.

*Invoice payments are not available for first-time visitors or overseas residents.

Cancellation Policy

Up to 15 days prior: Free of charge
14 to 8 days prior: 20% of total fee
7 to 1 day prior: 30% of total fee
On the day / No-show: 100% of total fee

*Schedule changes also incur these fees.

1. Residential Status

Where do you currently reside?

Required

JapanOverseas (Outside of Japan)

*Note for Overseas Residents: Please ensure you select one of our approved partners to coordinate your visit: View Medical Facilitators List.

2. Personal & Contact Information

First Name: (Exactly as it appears on your passport)

Required

Last Name: (Exactly as it appears on your passport)

Required

Gender

Required

Email address

Required

Phone number

Required

Current Address:

Required

*If living in Japan: Please provide your full domestic address. If living overseas: Please provide your City and Country of residence.

3. Medical & Insurance Details

Japanese Medical Insurance (Insured/Non-Insured):

Required

InsuredNon-Insured

Select your Screening Package / Plan:

Required

For detailed menus, please review our Screening Package Guide.

4. Preferred Dates

Required

1st Choice [ YYYY / MM / DD ]

2nd Choice [ YYYY / MM / DD ]

3rd Choice [ YYYY / MM / DD ]

5. Additional Details

Special Requests or Comments: If you have any allergies or specific religious dietary restrictions, please indicate them in the special requests section below.

For further inquiries, call: 03-5363-3045
(Monday through Friday, 9:00 am to 4:30 pm)