Contact Form

Smile Plan Dental Clinic Group Contact Form

There are two ways to book an appointment online.

The first is online reservation service. It is accurate and fast, but only available in Japanese.

Second, you can make a reservation by filling out this form in English to submit an email request.

Requested date※	First choice Requested date Reception Hours: Tues, Thurs, Fri, Sat, Sun 10:00 – 18:30, Wed 10:00 – 13:30 We are closed on Mondays and Japanese National Holidays. We ask that you arrive 30 minutes prior to your first appointment time for registration. Time Slot
Requested date※	Second choice Requested date Time Slot
Name (family name, given name)※
Your preferred name and title (Mr., Ms., Dr., etc.)
Please select your age range.※
Email address※
Telephone Number※	Please note: We are unable to place calls to international phone numbers at this time.
Please describe your Japanese ability.
Please describe your English ability.
Please check your concern or consultation topic. *Required, multiple selections OK	Toothache or sensitivity Chipped tooth Filling or crown came off Gum pain or swelling Bleeding gums Wisdom tooth pain / want extraction Concerned about canker sores / pain Want to whiten crown Orthodontic consultation Implant consultation Concerned about gaps between teeth Concerned about protruding teeth Gummy smile when smiling / treatment desired Wish whitening treatment Checkup / tartar removal
Inquiry

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

Office Hours	M	T	W	T	F	S	S
10:00-19:00	-	○	△	○	○	○	○