中村麻布十番クリニック NAKAMURA AZABUJUBAN CLINIC
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Visit & booking
Choose what you need General outpatient visits do not require booking
Request endoscopy Gastroscopy or colonoscopy Before your appointment Medication checks and what to bring General outpatient visits Hours and access Visit and booking guide
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Endoscopy booking

Request colonoscopy or gastroscopy

Choose your examination and confirm eligibility, complete the short questionnaire, then enter your preferred dates and contact details. Send everything together at the end. This form is for patients aged 18 or over requesting gastroscopy or colonoscopy. Submitting it does not confirm an appointment. The clinic reviews your request and sends an initial email. Your appointment is confirmed when you and the clinic agree on the date and time by email or phone. Visit without an appointment for general care, an undecided examination, or to discuss both examinations.

Preferred examination Required
Gastroscopy request

After the short questionnaire, select three preferred date-and-time combinations from the clinic schedule.

An in-person visit is required before colonoscopy

This applies to both first and return patients. Please visit the clinic in person by the day before the examination to receive the bowel preparation; no separate appointment is needed for this visit. The clinic checks the status of this visit before confirming the examination booking.

Status of your in-person visit Required
If any preferred examination date is the next day, select only the option confirming that you have already received the bowel preparation.
Reason for requesting endoscopy Required
If you only want a medical consultation or have not decided on endoscopy, please visit the clinic without using this form.

These short questions help the clinic review your request. They do not replace an in-person assessment or determine whether you can have an examination. Do not change or stop medicines based on this form.

Medical history or conditions currently being treated Required
Medicines you currently take Required
Allergies to medicines, foods, or other substances Required
Previous gastroscopy or colonoscopy Required
Sedation consultation Optional
Use is decided after reviewing your health, medication and examination details. Sedation does not always mean being fully asleep.
First or return visit Required
Language support and insurance Optional
These fields are optional. A translated webpage does not guarantee interpretation during care. The clinic will confirm available support before the appointment.
Online endoscopy requests are for patients aged 18 or over

Patients under 18 cannot submit this form. Please call the clinic before visiting.

Preferred examination dates and times First preference required

Choose your first preferred date and time. Second and third preferences are optional; if provided, choose both a date and time, with different combinations. Sending one preference does not guarantee an examination or your requested time. After reviewing your request, the clinic sends an initial email. The appointment is confirmed when you and the clinic agree on the date and time by email or phone.

Gastroscopy Mon/Tue/Wed/Fri: 10:00, 10:40, 11:40, 16:00, 16:20, 16:40, 17:00, 17:30 / Sat: 09:50, 10:20, 10:50

Colonoscopy Mon/Tue/Wed/Fri: 11:00, 12:00, 15:00 / Sat: 09:00

Preference 1 Required
Preference 2 Optional
Preference 3 Optional
Requestable times are checked against clinic days, public holidays and examination schedules when you choose a date and before sending. A selectable time does not guarantee that a slot has been reserved. Please arrange the actual date and time with the clinic.
Your booking request and short questionnaire are sent together

The clinic notification email includes your booking request and all questionnaire answers. Your automatic acknowledgment email does not include questionnaire answers and does not confirm an appointment. After reviewing your information, the clinic sends an initial email. Your appointment is confirmed when you and the clinic agree on the date and time by email or phone. The clinic will call if a medical check is needed.