Contact form

After entering the required information, click the "Confirm" → "Send" button.

If you are in a hurry, please contact us by phone.

Required fields are marked ※.

※Privacy policy

Handling of personal information

※Cancellation policy

Precautions for first-time patients

※Re-treatment/compensation policy

This fee applies only to free treatment provided at our clinic.

Please be sure to come for maintenance during the specified period. Please note that if you are not able to attend maintenance for a period of time, your product will not be covered by the warranty.

In the future, cavities or periodontal disease may develop and require treatment for the surrounding teeth as well. If the treated tooth has to be rebuilt at that time, it will not be covered by the warranty. note that.

※About minors

You can receive counseling only, but consent from a parent or guardian is required for treatment. When receiving treatment, you must be accompanied by a parent or have written consent from your parent. Please note that we may decline your request if either of these is not available. Please fill in the form in your own handwriting.

[Notes]

  • Entering information using a computer, etc. will be invalid. Please use something with indelible characters.
  • The signature and seal of the contracting party/parent is required.
  • If you do not bring it, our clinic will refuse the treatment or contract.
  • Please be sure to bring the original consent form.
  • An adult guarantor is required for split contracts for minors.
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Contact form