meclogoMinamiaoyama Eye Clinic Application Form

  • We are closed from December 29th (Sat) until January 4th (Fri).
    We will replay to your reservation and inquiry from January 5th (Sat), therefore our response will be late for a week at most.
    Thank you very much for your understanding.
    If there is an emergency, please call us.(03-5772-1451)

*First, please click here
FAQ

*It takes a couple of days to reply your E-mail. Please call us if you have any urgent request.

*Please fill in this form completely.

First&Last name*

Phone or cell phone*

E-mail Address*

E-mail Address（Re-type）*


Gender*
MaleFemale

Age*


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 a couple of days to reply your E-mail. Please call us if you have any urgent request.

    Thank you very much for your understanding.