Inquiry Form

Please fill in all required fields (*) accurately.

Clinic*

Your Name

First Name *

Middle Name

Last Name *

Phone*

(International format, e.g. +81...)

📱 International format required
🇯🇵 Japan: Local numbers starting with 0 → remove the 0.
Example: 080-1234-5678 → +818012345678 🇺🇸 US: Keep the area code as is.
Example: (310) 223-4567 → +13102234567 Format may vary by country.

Email*

Sex*

* Please select your biological sex at birth. It may affect treatment or prescriptions.

Date of Birth*

Nationality*

Counseling Topics*

Wrinkles Spots Sagging Anti-aging Hair Removal General skin concerns Body concerns

Message

You can use up to 500 characters.

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