In the event of inconsistency or discrepancy between the Japanese version and any other language version, the Japanese language version shall prevail.

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Interview sheet

Download and send medical questionnaire

You can download our medical questionnaire before your visit.
If you fill it out in advance, the reception on the day will be smooth.

Interview sheet

Download Interview Sheet

Once you have completed the questionnaire, please submit it to the reception when you come to the hospital, or send it using the form below.

Files up to 5MB can be sent.
(File format: jpg, jpeg, png, gif, pdf)


*If you are in a hurry, such as an emergency, please call Please contact us.
Phone：+81-3-6264-5528

Submission Form

    requiredName

    requiredEmail address

    requiredEmail address(Re-enter)

    requiredattaching file


    Within 5MB(format：jpg,jpeg,png,gif,pdf）

    optionalMessage (remarks column)

    ■Consent Matters for Acquisition of Personal Information

    Matsumoto Dental University Ginza 8-chome Clinic (hereinafter referred to as "our clinic") strives to properly and safely manage and operate personal information entrusted to us as follows.

    1. purpose of use
    We will use the collected personal information for the following purposes.
    ①For the provision of medical services
    (2) To explain medical conditions to family members
    ③ For medical insurance administration
    ④ For accounting and accounting
    ⑤For cooperation with other hospitals, insurance pharmacies, clinics, midwives, home-visit nursing care stations, nursing care service providers, etc.
    (6) To request advice from outside doctors, etc.
    ⑦ For in-hospital medical training and case studies

    2. Third party provision
    We will not provide personal data to third parties except in the following cases.
    ① When required by law
    (2) When it is necessary to protect a person's life, body, or property, and it is difficult to obtain consent from the individual.
    (3) When the patient is in a state of unconsciousness or doubts about the ability to make decisions, and it is necessary to inform the family or related organizations of the medical condition at the time of treatment.
    ④ When it is necessary for the improvement of public health and the sound development of children, and it is difficult to obtain the consent of the person.
    ⑤When it is necessary to cooperate in the execution of legal affairs by national institutions, local public bodies, their consignors, etc., and obtaining the consent of the person may affect the execution of affairs

    3. Disclosure request
    You have the right to request disclosure, correction, deletion, or suspension of use of your personal information. In the procedure, we will respond after confirming your identity, but it is also possible if it is a proxy. For details, please contact the "Personal Information Consultation Desk" below.

    Personal information consultation desk
    HULIC&New GINZA8 9F, 8-9-7 Ginza, Chuo-ku, Tokyo
    Matsumoto Dental University Ginza 8-chome Clinic Inquiries
    TEL: +81-3-6264-5528

    After confirming the agreement, check the box to agree and send.

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