03-5539-6191
Tue-Fri: 10:00-19:00 / Sat & Holidays: 9:00-18:00
VampireFacial
Stem Cell Supernatant
Fibroblast Transplantation
Have you visited our clinic before?Required
Full Name (in Japanese katakana)Required
Date of BirthRequired
Phone NumberRequired
* We may call you at this number if we are unable to reach you by email.
email addressRequired
What treatment(s) would you like to discuss with us?
* Multiple options can be selected.
I would like to discuss available options for regenerative medical treatment.
Please tell us a little more about your concerns.
Can you please describe your concerns in the box provided?
Please select the date on which you would like to visit our clinic.Required
※当日・翌日のご予約は、お電話のみの受け付けとなります。
※お急ぎの方は、お電話でのご連絡をお願いいたします。
* An interpreter will be required if you find it difficult to communicate in Japanese.
Thank you for your interest. We will get back to you with available dates and times. (* Please note that we may need to ask you to choose a different date and time if the one you have entered in this form has already been taken.)
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<How We Handle Your Personal Information> We handle your personal information, which we will collect via this form, in accordance with our Privacy Policy. Unless otherwise agreed upon between you and our clinic, we will never provide or disclose your personal information to a third party. For more details, please read our Privacy Policy.
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Have you visited our clinic before?
Full Name (in Japanese katakana)
Date of Birth
Phone Number
email address
Please select the date on which you would like to visit our clinic.
