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.