Counseling reservation form-AZABU SKIN CLINIC,Tokyo,Japan

AM10:00-PM7:00(Wednesday AM11:00-PM8:00 )
Clinic Free dial 0120-005-327
Free dial 0120-890-992

Counseling reservation

Reservation of free telephone counseling

0120-005-327 Free Dial
0120-890-992 Free Dial
*The consultation fee at our clinic costs 3,000 yen (Tax Exclusive).

Counseling reservation

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Please input necessary information into the following input form, and click "send" button.
Please understand it might be take some time for us to reply, however, we will try as early as we can.

You can also send FAX to us at 03-5798-4862 with completed Mail Consultation Form.

* mark is must be completed item
Inquiry item*
Full Name*
Patient type* first visit revisit

If you choose "revisit", please enter your medical record number

Sex* male  female
Occupation   Employee Student   Other
Address *(Please type in half-width characters)
(Please type in half-width characters)
*Please check if all information are correct before sending this form.
Reservation desired date*

Our clinic is closed on Mondays and Tuesdays.

*First choice

*2nd choice
*Closed on Monday, Tuesday
*If you make a reservation and in a hurry. Please call us within 3 days*Depending on the condition of medical treatment on the day, there maybe cases where the medical treatment time will be delay on the time of reservation.It is highly likely that you will have to wait especially on Saturdays. We will make every effort to provide medical treatment and treatment at the time you make a reservation, but please note that it may past the reservation time.
Desired treatment(multiple selections allowed)*

your specific concern or let us know the desired course of treatment.

It might be take some time for us to reply if the inquiry is sent on Saturday, Sunday, and public holiday. However, we will try as early as we can. Please call our clinic directly if you have an urgent request.

Carbomed / Therma cool / Photofacial(IPL) / Fillers?ECollagen?EHyaluronic acid / Dr's Chemical peeling (AHA,BHA,TCA) / Botox® / Injection (Lip augmentation,nose augmentation / Injections and infusions / Laser suregery / Piercing / Eczema,Atopic dermatitis / Excessive sweating,Botox® injection (Armpits,Palms) / Keloid / Wart,Mole / Laser hair removal / CET Thermotherapy / Endermologie /Ionization・ultrasound (Vitamin C,Hyarulonic acid) / Permanent for eyelashes / Acne / Acne Scar / Fractional Resurfacing / Growth Factor FGF?EEGF
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