AppointmentsRequest for Information Materials

Colon inspections without uncomfortable lavage solution
What is Day ESD

Request for Information Materials

Fields marked " " are mandatory. Please fill out completely.

Name Last   First 
Address Postal Code 

Telephone Number  (0797-35-8111)
Email Address
Sex  Male     Female
Date of Birth/Age  (01/25/2013)   yaers
Referrals  Who referred you to our clinic
(complete if someone introduced you to our clinic)
Please feel free to include any questions/comments/concerns below.
Gastrointestinal Endoscopy (Gastroenterology) Director / Hideki Mitooka
4-1-313 Funado-cho, Ashiya City, Hyogo, Japan Laporte Main Bldg. 3F Postal Code: 659-0093 TEL: 0797-35-8111
(c)2006 Ashiya Mitooka clinic All Rights Reserved.