meclogoMinamiaoyama Eye Clinic Application Form

    • Your appointment will be confirmed only when a member of our clinic staff contacts you by e-mail.
    • It takes a couple of days to reply your E-mail. Please call us if you have any urgent request.

      Consultation content*

      What is the reason for consultation?

      First&Last name*

      Phone or cell phone*

      E-mail Address*

      E-mail Address(Re-type)*



      ※Clinic close on Tuesday and Monday holiday .

      1st choice*

      2nd choice*

      3rd choice*

      If there is an emergency, please call us.(03-5772-1451)

      Reservation must be notified a few days in advance.

      Your correction procedure*
      GlassesSoft contact lensesHard contact lensesNothing

      Your past visits*

      Patient ID(Identification) card number

      Past history(e.g.LASIK)*

      Content of inquiry


      • If there is no reply even 10minutes or more, please call us(03-5772-1451).
        (9:30~18:00 clinic close on Tuesday and Monday of National holiday)
      • It takes about 2 hours for surgery examination and consultation.
      • We will put some medicine in your eyes to open your iris.
        Please do not come to our clinic by car.
      • The examination charge for the ReLEx SMILE, LASIK, and ICL is Free. Orthokeratorogy, we charge 3,000JPY for the examination. The rental charge for the trial lens is free.
      • The consultation charge (pre LASIK/SMILE/ICL/Orthokeratology) for the patients who could NOT speak English or Japanese will be 20,000 JPY.
      • We will charge 20,000 JPY for the second opinion in the patients who received refractive surgery (LASIK, ICL, etc).

      ※Minors must be accompanied by an adult.