First Visit Booking Form for Childbirth

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For those planning to give birth at Tokyo Adventist Hospital.
We do not accept deliveries for twin pregnancies, or for pregnancies following egg donation.

What happens next

Sending the email does not confirm a booking. We review each request, contact you by email, and confirm the date of your first visit.

This can take up to three clinic days.

Forms to bring to your first visit

The medical questionnaire, application form and personal information consent form can be downloaded from Booking Your Delivery & Prenatal Checkups.

Your details

Requiredfields must all be filled in.

About you

NameRequired

Name in katakana

If you are unable to write your name in katakana, please leave these fields blank and note this in the free text box below.

Date of birthRequired

AddressRequired

(with or without a hyphen)

Mobile numberRequired

Please give a number we can reach you on during the day. Hyphens are not required.

Email addressRequired

Please use an address that can receive our reply. If you filter by domain, please allow mail from the hospital.

About your pregnancy

First day of your last periodRequired

Pregnancy confirmed by a medical institutionRequired

ConfirmedNot confirmed

Expected delivery dateRequired

Not known

Please give the date you have been told by your current clinic.

Fetal heartbeat confirmedRequired

ConfirmedNot confirmedNot known

Preferred dates

Preferred dates for your first visit
Please give all three.Required

1st choice

2nd choice

3rd choice

Please choose dates between seven days and four weeks from today.
Obstetrics clinic hours are Monday to Wednesday 9:00 to 12:30 and 14:00 to 17:30, and Friday 9:00 to 12:30.
We may not be able to meet your preferred dates.
Tuesday and Wednesday afternoon clinics are staffed by a male doctor, and a male doctor may also be on duty at other times.

Anything else

Questions or requests

I would prefer not to be seen by a male doctor

Handling of personal information

Handling of personal information

The personal information collected here (name, telephone number, email address and so on) is used to receive your booking, confirm your identity, contact you, and respond to enquiries.

We do not provide personal information to third parties without your consent, except where required by law. We take appropriate measures to prevent loss, leakage or damage of personal information and to manage it safely.

For details, please see our privacy policy.

I have checked what I enteredRequiredI agree to the handling of personal informationRequired

Your details

Handling of personal information

Copy the text below and email it to us