Inquiry Form

Please fill in all required fields (*) accurately.

Inquiry Type*
※ If you are considering liposuction, please select "Counseling".
Clinic*
Your Name
Phone*
📱 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*
Residence / Stay*
This may affect whether certain treatments can be performed.

Counseling Topics*
※At least one counseling topic is required.
※ For Liposuction, please select at least one treatment.
Patient Information
Patient Information is required for Liposuction only.


or feet / inch
or pound (lb)
This is a converter for feet/inches to cm and pounds to kg. We use cm/kg in Japan.
0 / 200 characters
0 / 200 characters
At least one date is required and select the date in Japan Standard Time.
Message
You can use up to 500 characters.
0 / 500
Precautions
Important Precautions