In-Person Clinic Consultation Reservation

We will answer your problems or questions. Please feel free to consult us.
The items with the symbol mean that they are necessary for everyone to fill out.
●Please do not use half-size ‘katakana’

Full Name (Last name, First name)
years old
Telephone number
※If we may not be able to contact you by email, we will get in touch with you by phone. Please fill in the phone number with country code (if applicable) which we can get in touch with you during the daytime.
Email address
(In half-size alphabets)
※If you are filling in this blank with a mobile mail address, please change the condition of your mobile to allow accepting emails from “”.
We will send a response email automatically right after a contact is made. If you do not get this automatic response, please check your spam box or let us know.
Email address
(For confirmation)
Appointment location
The part you are worried about
First preferred date
Second preferred date
How fluent
are you in the Japanese language?

Remarks column
If you have any requests or questions,
please fill in.

Please check the following content concerning personal information

・About the personal information we ask for on this WEB site

This WEB site is operated in order to provide better medical services to our patients. This WEB site requires one to input data on personal information (such as his/her name, address, email address, and other personal data) upon receiving application for counseling reservation and mail consultation through emails. This information is necessary to carry out more accurate counseling and to get into contact with the person in question in an accurate way.

・About managing and utilizing personal information

Our clinic will control the handling of the personal information with great care and will pay the greatest attention to the safe handling. The targeted personal information is our patients’ name, address, age, sex, phone number, email address, or such information that can identify the individual who is our client.

In order to provide better medical services, there are some occasions where we will outsource the handling of personal information we have been given. In this case, our clinic will bear responsibility to guide and direct the outsourcing company so as not to let personal information be leaked. And without identifying our each patient, there are also some occasions where we use personal information to collect the total number of our patients as well as the statistical data of the number of people who have visited our WEB site.

・About disclosure, correction, and deletion of personal information

As for disclosure, correction, and deletion of personal information, please contact the following email address.

After checking whether he/she is our real client, we will take quick measures in order not to let the personal information be leaked. And as for disclosure, there are cases where we disclose the provided personal information if it fits any of the following items.

1)If it becomes clear that our patient has brought disadvantages to our other patients, our clinic will notify of personal information to such parties, police, and other relevant organizations.

2)There are cases where we will disclose personal information upon a request for us to officially disclose was made by public organizations such as courts or police or organizations with similar power.

3)There are cases where our clinic will outsource the handling of personal information in order to provide better medical services to our patients.

・Inquiries on personal information

If you have any questions or opinions, please contact the following email address.
Shinwa Clinic Management Office

・About revision of our privacy policy

As for “our privacy policy,” we will review and make necessary revisions appropriately.

・Governing law

This WEB site as well as construction and application of its usage conditions are governed by the laws of Japan.