Contact Forms

Booking Request

Preferred Date
Select Candidate time※ up to 5

0/5 Selected
Select Location (State)
Select a Consultation Type
※In-person consultations are available only in Tokyo, Chiba, Saitama, and Kanagawa.
Input a Symptoms
※In Japan, patients living outside the country cannot receive prescriptions for ADHD medications.

Patient's information

First name
Last name
Date of Birth
Gender
Nationality

Contact & Consent

                       
Phone number
E-mail
Have travel insurance
with medical coverage
Contact method