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Reservation/Inquiry Form

If you do not receive an automatic reply e-mail from our clinic, there is a possibility that the e-mail address was entered incorrectly or it was sorted into the spam folder.
If you do not receive a reply within 2 days, excluding holidays, please contact us by phone.

*Please note that depending on the content of the treatment, it may take some time and you may have to wait.

Is this your first visit to our hospital?【※required】	first time 2nd time onwards
Desired treatment/surgery	Cosmetic Dermatology and Cosmetic Surgery (Own Expenses) Plastic surgery (insurance treatment)
Desired reservation date and time *Surgery hours are from 14:00 to 16:30.	1st Choice【※required】 schedule time zone 2nd Choice schedule time zone 3rd choice schedule time zone
Name【※required】
Gender【※required】	female male
Date of Birth【※required】	年　　月　　日 *Minors need parental consent form PDF download
Prefecture where you live【※required】
Phone number【※required】
E-mail address【※required】
E-mail address (for confirmation)【※required】
Consultation/Inquiries

* The following links are in Japanese. Please use Google Translate to automatically translate.

PAGETOP