meclogoMinamiaoyama Eye Clinic Application Form

  • Please note that your preferred appointment date may not be available.
  • Since we prepare our schedule in advance, appointments will only be available for a date four days hence.
  • Your appointment will be confirmed only when a member of our clinic staff contacts you by e-mail.


Mandatory fieldWhat kind of surgery are you interested in?

※Minors must be accompanied by an adult.

*Please fill in this form completely.

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*

Your correction procedure*
GlassesSoft contact lensesHard contact lensesNothing

Your past visits*

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 first 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 cost of examination of ReLEx SMILE,LASIK,ICL is Free.In Orthokeratorogy, free of examination, The cost of lent out the lens is 3,000yen.