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. Your appointment is confirmed only after review and a call from the clinic. 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 will call to confirm 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 All required

Choose three different date-and-time combinations. These are requests only; the appointment is confirmed after the clinic calls you.

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 Required
Preference 3 Required
Closed days and current availability are checked by the clinic. Please select Monday, Tuesday, Wednesday, Friday, or Saturday.
Your booking request and short questionnaire are sent together

The clinic notification email includes your booking request and all questionnaire answers. Your confirmation email does not include questionnaire answers. The clinic reviews the information and calls to confirm the appointment.