tokyo skin clinic

Fill out the form below and click "submit".



Are you already a registered patient of Tokyo Skin Clinic?

— enter your ID number here:
     You can skip the next block of questions.


     Please continue to the next block of questions.


Not necessary to fill out if you have your ID number

Sex
Age  years
Place of residence (country, municipality)
 
Postal Code
Telephone
Main problem you wish to see a doctor about:
Was our clinic recommended to you by one of our patients? 

Give three preferences after checking the days the clinic is open on the web calendar. Please choose dates within three months from today.

 
First Preference
 
Second Preference
 
Third Preference

Do you wish to undergo a procedure or a laboratory test?
 
procedure (specify):
laboratory test (specify):