{"id":88,"date":"2015-12-13T14:16:41","date_gmt":"2015-12-13T05:16:41","guid":{"rendered":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/?page_id=88"},"modified":"2026-03-01T13:39:20","modified_gmt":"2026-03-01T04:39:20","slug":"en","status":"publish","type":"page","link":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/en\/","title":{"rendered":"Appointment"},"content":{"rendered":"<h4><a href=\"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-content\/uploads\/2015\/11\/meclogo.jpg\"><img loading=\"lazy\" class=\"alignnone size-full wp-image-37\" src=\"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-content\/uploads\/2015\/11\/meclogo.jpg\" alt=\"meclogo\" width=\"54\" height=\"54\" srcset=\"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-content\/uploads\/2015\/11\/meclogo.jpg 297w, https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-content\/uploads\/2015\/11\/meclogo-150x150.jpg 150w\" sizes=\"(max-width: 54px) 100vw, 54px\" \/><\/a><strong>Minamiaoyama Eye Clinic Application Form<\/strong><!-- Due to a power outage throughout the building, we will be closed on the morning of Sunday, March 1. The clinic will reopen as usual in the afternoon.Web reservations are also not available. --><!--\/\/\u505c\u96fb--><\/h4>\n<ul>\n<li>Your appointment will be confirmed only when a member of our clinic staff contacts you by e-mail.<\/li>\n<li>It takes a couple of days to reply your E-mail. Please call us if you have any urgent request.<\/li>\n<li><strong>This appointment form is for pre-surgical examinations only.<\/strong><br \/>\n<strong>For all other appointments, please make your appointment<a href=\"https:\/\/ssc5.doctorqube.com\/minamiaoyama\/English\/\"><span style=\"color: #ff0000;\"> here<\/span><\/a>.<\/strong><\/li>\n<li><span style=\"color: #ff0000;\"><strong>Currently, appointments are fully booked. Please schedule your appointment for a date at least two weeks from now.<\/strong><\/span><\/li>\n<\/ul>\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f90-o1\" lang=\"ja\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/yoyakuform\/wp-json\/wp\/v2\/pages\/88#wpcf7-f90-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"90\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f90-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div id=\"tekioukensayoyaku\">\n<h3 class=\"title-contactform7 inv\">\nConsultation content*<\/h3>\n<div class=\"formitem inv\">\n<span class=\"wpcf7-form-control-wrap radio-814\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-814\" value=\"LASIK\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">LASIK<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-814\" value=\"SMILE\" \/><span class=\"wpcf7-list-item-label\">SMILE<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-814\" value=\"PRK\" \/><span class=\"wpcf7-list-item-label\">PRK<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-814\" value=\"ICL\" \/><span class=\"wpcf7-list-item-label\">ICL<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-814\" value=\"Cataract surgery\" \/><span class=\"wpcf7-list-item-label\">Cataract surgery<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<p><br><\/p>\n<p style=\"padding-left: 20px;\">What is the reason for consultation?<br \/>\n<br \/><span class=\"wpcf7-form-control-wrap textarea-253\"><textarea name=\"textarea-253\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<p><!--\n<p style=\"padding-left: 20px;\"><strong><span class=\"asterisk\">*<\/span>Please fill in this form completely.<\/strong><\/p>\n<p><br\/>--><\/p>\n<p style=\"padding-left: 20px;\">First&Last name<span class=\"asterisk\">*<\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap your-name\"><input type=\"text\" name=\"your-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g.)Tony Fox\" \/><\/span> <\/p>\n<p style=\"padding-left: 20px;\">Phone or cell phone<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap tel-358\"><input type=\"tel\" name=\"tel-358\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g.\uff0909012345678\" \/><\/span><\/p>\n<p style=\"padding-left: 20px;\">E-mail Address<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g.\uff09mataro@gmail.com\" \/><\/span><\/p>\n<p style=\"padding-left: 20px;\">E-mail Address\uff08Re-type\uff09<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap your-email_confirm\"><input type=\"email\" name=\"your-email_confirm\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/p>\n<p style=\"padding-left: 20px;\">Gender<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap radio-812\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-812\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"radio-812\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-812\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><\/p>\n<p style=\"padding-left: 20px;\">Age<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap menu-684\"><select name=\"menu-684\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><option value=\"32\">32<\/option><option value=\"33\">33<\/option><option value=\"34\">34<\/option><option value=\"35\">35<\/option><option value=\"36\">36<\/option><option value=\"37\">37<\/option><option value=\"38\">38<\/option><option value=\"39\">39<\/option><option value=\"40\">40<\/option><option value=\"41\">41<\/option><option value=\"42\">42<\/option><option value=\"43\">43<\/option><option value=\"44\">44<\/option><option value=\"45\">45<\/option><option value=\"46\">46<\/option><option value=\"47\">47<\/option><option value=\"48\">48<\/option><option value=\"49\">49<\/option><option value=\"50\">50<\/option><option value=\"51\">51<\/option><option value=\"52\">52<\/option><option value=\"53\">53<\/option><option value=\"54\">54<\/option><option value=\"55\">55<\/option><option value=\"56\">56<\/option><option value=\"57\">57<\/option><option value=\"58\">58<\/option><option value=\"59\">59<\/option><option value=\"60\">60<\/option><option value=\"61\">61<\/option><option value=\"62\">62<\/option><option value=\"63\">63<\/option><option value=\"64\">64<\/option><option value=\"65\">65<\/option><option value=\"66\">66<\/option><option value=\"67\">67<\/option><option value=\"68\">68<\/option><option value=\"69\">69<\/option><option value=\"70\">70<\/option><option value=\"71\">71<\/option><option value=\"72\">72<\/option><option value=\"73\">73<\/option><option value=\"74\">74<\/option><option value=\"75\">75<\/option><option value=\"76\">76<\/option><option value=\"77\">77<\/option><option value=\"78\">78<\/option><option value=\"79\">79<\/option><option value=\"80\">80<\/option><\/select><\/span><\/p>\n<p style=\"padding-left: 20px;\"><font color=\"red\">\u203bClinic close on Tuesday and Monday holiday .Currently, appointments are fully booked. Please schedule your appointment for a date at least three weeks from now.<\/font><\/p>\n<p style=\"padding-left: 20px;\">1st choice<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap text_day1\"><input type=\"text\" name=\"text_day1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"2025\/01\/23(Year\/Month\/Day)\" \/><\/span><span class=\"wpcf7-form-control-wrap menu-youbi01\"><select name=\"menu-youbi01\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Mon\">Mon<\/option><option value=\"Wed\">Wed<\/option><option value=\"Thu\">Thu<\/option><option value=\"Fri\">Fri<\/option><option value=\"Sat\">Sat<\/option><option value=\"Sun\">Sun<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap menu-308\"><select name=\"menu-308\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"9:30\uff5e11:00\uff08AM\uff09\">9:30\uff5e11:00\uff08AM\uff09<\/option><option value=\"13:30\uff5e14:30\uff08PM1\uff09\">13:30\uff5e14:30\uff08PM1\uff09<\/option><option value=\"15:00\uff5e16:00\uff08PM2\uff09\">15:00\uff5e16:00\uff08PM2\uff09<\/option><\/select><\/span><\/p>\n<p style=\"padding-left: 20px;\">2nd choice<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap text_day2\"><input type=\"text\" name=\"text_day2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"2025\/01\/23(Year\/Month\/Day)\" \/><\/span><span class=\"wpcf7-form-control-wrap menu-youbi02\"><select name=\"menu-youbi02\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Mon\">Mon<\/option><option value=\"Wed\">Wed<\/option><option value=\"Thu\">Thu<\/option><option value=\"Fri\">Fri<\/option><option value=\"Sat\">Sat<\/option><option value=\"Sun\">Sun<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap menu-309\"><select name=\"menu-309\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"9:30\uff5e11:00\uff08AM\uff09\">9:30\uff5e11:00\uff08AM\uff09<\/option><option value=\"13:30\uff5e14:30\uff08PM1\uff09\">13:30\uff5e14:30\uff08PM1\uff09<\/option><option value=\"15:00\uff5e16:00\uff08PM2\uff09\">15:00\uff5e16:00\uff08PM2\uff09<\/option><\/select><\/span><\/p>\n<p style=\"padding-left: 20px;\">3rd choice<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap text_day3\"><input type=\"text\" name=\"text_day3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"2025\/01\/23(Year\/Month\/Day)\" \/><\/span><span class=\"wpcf7-form-control-wrap menu-youbi03\"><select name=\"menu-youbi03\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Mon\">Mon<\/option><option value=\"Wed\">Wed<\/option><option value=\"Thu\">Thu<\/option><option value=\"Fri\">Fri<\/option><option value=\"Sat\">Sat<\/option><option value=\"Sun\">Sun<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap menu-310\"><select name=\"menu-310\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"9:30\uff5e11:00\uff08AM\uff09\">9:30\uff5e11:00\uff08AM\uff09<\/option><option value=\"13:30\uff5e14:30\uff08PM1\uff09\">13:30\uff5e14:30\uff08PM1\uff09<\/option><option value=\"15:00\uff5e16:00\uff08PM2\uff09\">15:00\uff5e16:00\uff08PM2\uff09<\/option><\/select><\/span><\/p>\n<p>If there is an emergency, please call us.(03-6633-4872)<br><br \/>\nReservation must be notified a few days in advance.<\/p>\n<p><\/br><\/p>\n<p style=\"padding-left: 20px;\">Your correction procedure<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap checkbox-12\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Glasses\" \/><span class=\"wpcf7-list-item-label\">Glasses<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Soft contact lenses\" \/><span class=\"wpcf7-list-item-label\">Soft contact lenses<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Hard contact lenses\" \/><span class=\"wpcf7-list-item-label\">Hard contact lenses<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Nothing\" \/><span class=\"wpcf7-list-item-label\">Nothing<\/span><\/span><\/span><\/span><\/p>\n<p style=\"padding-left: 20px;\">Your past visits<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap radio-815\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-815\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-815\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/p>\n<p>Patient ID(Identification) card number<br \/>\n<span class=\"wpcf7-form-control-wrap text-295\"><input type=\"text\" name=\"text-295\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/P><\/p>\n<p style=\"padding-left: 20px;\">Past history(e.g.LASIK)<span class=\"asterisk\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap radio-816\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-816\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-816\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/p>\n<p><\/br><\/p>\n<p style=\"padding-left: 20px;\">Content of inquiry<br \/>\n<span class=\"wpcf7-form-control-wrap textarea-737\"><textarea name=\"textarea-737\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<h4 class=\"warning mt15 mb10\">Notes<\/h4>\n<div style=\"border:1px solid #ccc;height:330px;overflow:auto;width:92%;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;background-color:#f7f7f7;margin:auto;padding:10px;\">\n<ul style=\"list-style-type: disc;\">\n<li>If there is no reply even 10minutes or more, please call us(03-6633-4872).<br \/>\n      \uff089:30\uff5e18:00\u3000clinic close on Tuesday and Monday of National holiday\uff09<\/li>\n<li>It takes about 2 hours for surgery examination and consultation.<\/li>\n<li>We will put some medicine in your eyes to open your iris.<br \/>\n            Please do not come to our clinic by car.<\/li>\n<li>The examination charge for the LASIK,SMILE,PRK,and ICL is Free. Orthokeratorogy, we charge 3,000JPY for the examination. The rental charge for the trial lens is free.<\/li>\n<li>If communication in Japanese or English is difficult, patients are kindly requested to bring their own interpreter. Please note that when an interpreter accompanies the patient, an initial suitability examination fee of 20,000 yen will apply. <\/li>\n<li>We will charge 20,000 yen for a second opinion for patients who have received refractive surgery (LASIK, ICL, etc.). If an interpreter accompanies the patient, the fee will be 40,000 yen.<\/li>\n<\/ul>\n<p>\u203bMinors must be accompanied by an adult.<\/p>\n<\/p><\/div>\n<p><br><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<p style=\"text-align: center;\">\n  <input type=\"submit\" value=\"submit\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<p><br>\n<\/div>\n<p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"186\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Minamiaoyama Eye Clinic Application Form Your appointment will be confirmed only when a member of our clinic s &hellip; <a href=\"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/en\/\" class=\"more-link\">\u7d9a\u304d\u3092\u8aad\u3080 <span class=\"screen-reader-text\">Appointment<\/span> <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-caten.php","meta":{"om_disable_all_campaigns":false,"_mi_skip_tracking":false},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/pages\/88"}],"collection":[{"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/comments?post=88"}],"version-history":[{"count":69,"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/pages\/88\/revisions"}],"predecessor-version":[{"id":921,"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/pages\/88\/revisions\/921"}],"wp:attachment":[{"href":"https:\/\/www.minamiaoyama.or.jp\/yoyakuform\/wp-json\/wp\/v2\/media?parent=88"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}