Appointment Form

Please fill in all required fields (*) accurately.

Clinic*
Your Name
Email*
Counseling Topics*
※At least one counseling topic is required.
※ For Liposuction, please select at least one treatment.
Counseling Date
Preferred Date 1
* Please select a date in Japan Standard Time.
Preferred Date 2
* Please select a date in Japan Standard Time.
Preferred Date 3
* Please select a date in Japan Standard Time.
Patient Information
Patient Information is required for Liposuction only.


* Please select desired treatments 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.
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List any diagnosed medical conditions you currently have, whether you are under treatment or not. (e.g., Hypertension, Diabetes, Asthma)

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At least one date is required and select the date in Japan Standard Time.
Message
You can use up to 500 characters.
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Precautions
Important Precautions