本文へスキップ
For Your Smile, Sense Of Well-being.                                              日本語

Monday-Saturday:10:00-19:00/Close:Sunday・Holiday

4−25−1 Minami Aoya Minatoku Tokyo 107-0062  03-6427-2025

After Birth Treatment - Reservation Formreserve

*Please note that all fields followed by an asterisk must be filled in.

Name*
 E-mail*
 Phone number*  cell-phone home number
Address zip-code
information Birth: M D Y  
Age  nationality
Apoitment
Day & Time
First choice*
M D Day Time
Secound choice
M D Day Time
 Menu  
date of last childbirth* M d Y age
About childbirth* How many times do you experience childbirth?  time(s)
Is it includeing twinning? No Yes
Do you have a history of a previous pregnancy resulting in giving birth with a c-section? No  Yes
 Medical History Please describe about your condition.
for example)
Aug 15.,2013(age36) got pregnant naturally and delivered first child with C-seciton.  during pregnancy: severe hyperemesis gravidarum
Sep 10.,(age36) wrist hurts, fatigue, lack of sleep

Did you tried any treatment or massage after birth?
No Yes
 If Yes, :()
Do you have any trouble of breast-feeding?
No Yes()
tarminated brest-feeding
Do you have any surgical history or chronic disease?
No Yes()
Do you take any medicine?
No Yes ()
Do you have any allergic?
No Yes()
Other Medical Information   Do you have a gastrointestinal discomfort? No Yes
Do you a experience urinary frequency? No Yes
Do you have an irregular eating habits? No Yes
Do you have a sleep-related problem? No Yes
Do you have a cold constitution? No Yes
 Remarks column
Question