Reservation with questionnaire in English

Reservation with questionnaire in English

Send a reservation of the questionnaire

* indicates required field

Name:*

Email:*

Date of Birth:*

Nationality:*

Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Other region

First medical examination - re-examination:*

First medical examination Re-examination

Where to Visit:*

Shinjuku West Clinic
Shibuya West Clinic

Booking dates:*

Desired reservation time:*

01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

Clinical subjects:*

ED AGA ED and AGA

Prescription desired:*

Viagra Sildenafil (Viagra generics) Levitra Cialis Propecia Finasteride (Propecia generic) Zagaro Arobikkusu solution (application hair growth) Minoxidil (application hair growth)

Address:*

Phone number:*

Occupation:

Height:*

Weight:*

Do you have allergies?:*

No
Yes

If Yes, please inform:

Do you have a chronic disease or a history?:*

No
Yes

If yes, please inform the name of a disease:

Is there any medicine that you continue to take often?:*

No
Yes

Have you ever had a major illness or surgery?:*

No
Yes

If Yes, please inform:

Please write anything about your body that you concern:

Have you been prescribed nitroglycerin for heart attack?:*

No
Yes

Do you have Heart related, capillary system, or liver disorder?*

No
Yes

Have you had Cerebral infarction, cerebral hemorrhage, myocardial infarction in last six months?:*

No
Yes

Have you ever used Viagra, Levitra, Cialis, Propecia, or Zagaro?*

No
Yes

Retinitis pigmentosa:*

No
Yes
Do not know

Bood pressure:*

High
Normal
Low

CAPTCHA Code:*

関連情報:

Shinjuku West Clinic for ED and AGA 新宿西诊所 AGA, ED 新宿西診所 予約フォーム 料金表 新宿ウエストクリニック ED治療・AGA治療 ご予約フォーム(外来・問診票付) プロペシア処方 バイアグラ処方 プロペシア 注意が必要なED薬品一覧 サイトマップ