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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

Fertility Ready For Pregnant - 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 marriage  date Single
 Starting date of infertility treatment in hospital  date  not starting
 Bssic tests Please discribe the things are pointed out in hospital. 
(hysterosalpingography, hormone levels)
Medical History Please describe your history of medical treatment including the presence or absence of fibroid...
for example)
2010(age 30) started checking of precise date of ovulation in
 ○○hospital
2013(age 33)started artificial insemination

Other Medical Information   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()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
An average menstrual cycle days
 Do you have a premenstrual syndrome? No Yes
  If Yes ()
Do you have a cold constitution? No Yes
 Remarks column
Question