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Smile Plan Dental Clinic Group Contact Form

There are two ways to book an appointment online.

You can make a reservation request by filling out this contact form in English. After submitting it, we’ll contact you by email to set a time.

Alternatively, you can use our online reservation service. It is accurate and fast, but only for first-time patients, and only available in Japanese.

Patient Status.※

Are you a first-time patient or a returning patient?
Patient Number (optional)

For returning patients only:
Please enter your patient number. This is the number (“No.”) above your name in the MyDental app.
If you are unsure or do not have the MyDental app,
Patient Number please leave this space blank.
Requested date※

First choice

Requested Date

We are closed on Mondays, Wednesday afternoons, and Japanese National Holidays.
We ask that you arrive 30 minutes prior to your first appointment time for registration.

We are unable to reserve appointments by email less than 2 days in advance. For immediate appointments, please call us at
06-6633-2828.

Time Slot

Second choice

Requested Date
Time Slot
Your Name
(Family Name, Given Name)※
Your Preferred Name/Title
Your Age※
Email Address※
Telephone Number※

Please note: We are unable to place calls to international phone numbers at this time.
Please describe your Japanese language ability.
Please describe your English language ability.
What is the main reason for your visit? (choose one)※
Please check any additional reason(s) for your visit. (optional)
Please write any other details, questions, etc., that you might have.

Medical Questionnaire

Please print and complete this questionnaire,
then bring it with you to your appointment.

Download
For first-time patients only
Online reservation