Inquiry Form for International Patients (English-Speaking Countries)

Basic Information (Required)

Full NameRequired

Email AddressRequired

WhatsApp Number (Optional)

WeChat ID (Optional)

Country of ResidenceRequired

Age Required

Treatment Interest

Treatments of Interest (Multiple selections allowed)

Double Eyelid SurgeryEye Area TreatmentDermal FillersThread LiftRegenerative Medicine (iPS Factor Injection)AGA / Hair Loss TreatmentOther (please specify)

Main Concern / Consultation Details

Online Consultation

Would you like to have an online consultation?

YesNo

*Online consultation is for preliminary guidance only. Final diagnosis and treatment decisions will be made after an in-person examination at our clinic.

Preferred Online Consultation Date & Time（Please provide up to three preferred options:）

1st Choice：

2nd Choice：

3rd Choice：

*Please indicate Japan Standard Time (JST).

Visit Plan to Japan

Preferred month of visit

Planned length of stay in Japan

Is this your first visit to Japan? (Yes / No)

YesNo

Medical Safety Confirmation

Have you had similar treatments before? (Yes / No)

YesNo

Do you have any current medical conditions? (Optional)

Are you currently taking any medications? (Optional)

Photo Upload (Optional)

Upload front and side facial photos (Maximum 5MB)

Upload front and side facial photos (Maximum 5MB)

*Photos are used solely for preliminary medical evaluation.

Explicit Consent (Required)

I understand that online consultation is not a final medical diagnosis.
I understand that final treatment decisions will be made after an in-person examination.
If I provide medical information or facial photographs, I consent to the collection and use of such sensitive information.
I consent to the storage of my personal data in Japan and to possible cross-border data transfer outside my country of residence.
I have read and agree to the Privacy Policy.

Privacy Policy (For International Patients)

This form uses Akismet to reduce spam. Learn how your data is processed.