Download Patient Intake Form

Download Patient Intake Form

Before we begin your treatment, you are required to download the applicable forms below and fill them out before your visit.
If you have any trouble downloading and printing our forms, they are also available at our office.
You may either pick them up, or  contact us if you would like them mailed to you, or complete the form in our office at the time of your first visit. (You are requested to come 15 to 20 minutes earlier if you wish to complete the form at the office.)

For General Treatment
For Female Fertility Treatment
For Male Fertility Treatment

Fertility Treatment
Other Areas of Expertise
Acura Acupuncture Clinic Tokyo
(Shibuya St., Omotesando St., Aoyama)

Please contact us to make an appointment.

Office Hours (Closed on Tuesday)
10:00 – 21:00 (Mon / Wed)
9:30 – 21:00 (Thu / Fri)
9:30 – 18:00 (Sat, Sun, National Holidays)