Request Form: Giving Birth at Our Clinic

If you wish to give birth at our clinic, please use the form below to submit your request.

Please note that this will be a temporary reservation at first. Upon receiving your request, we will contact you to finalize a date and time. If you do not receive an automatic confirmation email after submitting the request form, please check your spam folder. As emails sometimes fail to deliver, we will contact you by phone.

Request Form

Please complete the required fields in the form below and click the “Submit” button. You do not need to answer every question; please fill out the form to the best of your ability.

YYYY slash MM slash DD
YYYY slash MM slash DD
History of Pre-existing Conditions(Required)
*If Other, please fill in the name of the illness.
Number of Previous Deliveries(Required)
*If three or more times, please fill in the number.
Experience with Cesarean Section(Required)
*If Yes, please fill in the number of times.

3-14-19 Kamiosaki, Shinagawa-ku, Tokyo 141-0021

TEL:03-6450-3850 FAX:03-6432-5573

Email: office@tokyobirthclinic.com

Call Us
03-6450-3850