Application Form for COVID-19

    PCR Test and Antibody Test


    This is application form for COVID-19 PCR Test and Antibody Test by Takanawa Clinic.

    Please fill in the required information. After receiving your application, we provide the inspections explanations and reservations from reception desk. At that time, please let me know preferred date would you like to make a reservation.

    Please contact below e-mail address if you’d like to apply a group or corporation.
    E-mail Address:

    *There are cases in which we must send information about COVID-19 from Ministry of Health, Labour, and Welfare.

    RequiredWhich test do you want?
    RequiredHave you tested positive for Covid-19 in the past?
    RequiredDate of birth

    RequiredPhone Number
    RequiredZip Cord
    RequiredState / Province
    RequiredStreet Address
    RequiredE-mail Address
    RequiredE-mail Address Retype
    RequiredPreferred date of phone call from Clinic
    RequiredPreferred time of phone call from Clinic

    Consent for the Treatment of Personal Data

    1.Company name

    Takanawa Clinic

    2.The name of the business operator handling personal information.

    Yasunari Kageyama

    TEL: 03-6433-3165

    3.Purpose of use of personal information that we acquired by the application form.

    The Personal Information we have collected shall be managed with strict accuracy and used within the scope of the purpose of use which we have clarified.

    ・Attend to customer enquiries

    ・To contact you with response to your inquiry

    4.About outsourcing of personal information to a third party.

    In case, we may outsource the management of personal information to a third party.

    5.About offer and sharing to a third party of the personal information.

    The personal information is not offered or shared to a third party with the exception of the circumstances outlined below.

    ・Cases in which the handling of personal information is based on laws and regulations.

    ・Cases in which the provision of personal data is necessary for the protection of the life,
    body, or property of an individual.

    ・When the applicant agrees.

    6.Safety management for privacy protection.

    We have rules to protect personal information. We will inform, enlightenment and education for our employees and carry out audits on a regular basis.

    We keep and improve safety measures required to protect your personal information.

    7.Procedures such as disclosure, correction, suspension of personal information.

    If you request for the disclosure, notice of the purposes of use, correction, addition, deletion, discontinuance of use, elimination or discontinuance of provision to a third party of any personal information, please contact below enquiry desk.

    <Inquiries regarding the Personal Information Protection Policy>


    8.If you do not accept the agreement.

    Personal information is provided to the voluntarily. If you do not agree, please note that we might not be able to achieve our purpose of use in Article (3).

    9.Operation of our website

    We may use a technology called "Cookie" to make it more convenient for you to browse, when you will revisit our website. Cookie records that you visit which page of our website from your computer, however, unless personal information is entered into our website by visitors, it is impossible to identify specific users. You may refuse to accept cookies by altering the settings on your internet browser. Please note that if you refuse to accept cookies from this website, you will not be able to access portions of our website.

    Takanawa Clinic