Counselling Appointments

Counselling Appointments

If you would like to schedule a counseling session, please fill out the form below.
An initial consultation fee of 2,200 yen is charged at the time of the first visit.

  • INPUT
  • SEND

Filling out the online form takes about 2 minutes.

Give the preferred date and time of your visit

Give your first choice date and timeRequired

Give your second choice date and timeRequired
About the Treatment

Please select the preferred treatment from the multiple choice menu.

Would you like to be a case monitor?Required

Is this your first visit to our clinic?Required
Full NameRequired

Date of BirthRequired

example: 12/05/2020 → 12052020
Contact Information

Phone NumberRequired

Mail AddressRequired
Other questions or requests

Image Attachments

×
×
×

Questions / RequestsRequired