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.
  • The consultation charge (pre LASIK/SMILE/ICL/Orthokeratology) for the patients who could NOT speak English or Japanese will be 20,000 JPY from January 2019.

 

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)*


Gender*
MaleFemale

Age*


※Clinic close on Tuesday and Monday holiday .

1st choice*

2nd choice*

3rd choice*


Your correction procedure*
GlassesSoft contact lensesHard contact lensesNothing

Your past visits*
YesNo

Past history(e.g.LASIK)*
YesNo


Content of inquiry

Notes

  • 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 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 from January 2019.