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NameRequired

Last name

First name

Date of BirthRequired

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※Please enter in single-byte number.

Email addressRequired

First choiceRequired

Select time 10:00 10:30 11:00 11:30 12:00 12:30 13:00 13:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00

※Closed on Mondays and Tuesdays.

2nd choiceRequired

Select time 10:00 10:30 11:00 11:30 12:00 12:30 13:00 13:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00

* Closed on Mondays and Tuesdays.

Convenient times
for your visitRequired

※Please note that we may not be able to accommodate your request depending on availability. We appreciate your understanding.

Reception

Wed.

Thu.

Fri.

Sat.

Sun.

10:00-13:00

Wednesday 10-13 Thursday10-13 Friday10-13 Saturday10-13 Sunday10-13

15:00-17:00

Wednesday 15-17 Thursday15-17 Friday15-17 Saturday15-17 Sunday15-17

17:00-18:30

Wednesday 17-half past 18 Thursday17-half past 18 Friday17-half past 18 Saturday17-half past 18 Sunday17-half past 18

Do you have dates not bookable?

Yes　 No

Details of dates
that cannot be booked
※Only for those who have dates that cannot be booked.

Is this your first time
using our clinic? Required

First time Previously Used

Concerns
(Multiple selections possible)Required

Skincare Elisisense Photo Facial Fat Dissolving Injection Botox Double eyelid surgery Thread lift Dark circle removal Exosome Drip Indiba Bust Up ED Treatment Medical Hair Removal Doctor's Cosmetics Medical Diet

Regarding
Counseling/ConsultationRequired

I only want counseling Considering Treatment I have decided on a specific treatment

Please tell us about your current concerns. Also, if there is a specific treatment you definitely want, please specify.

Handling of
Personal InformationRequired

I agree to the handling of personal information

Handling of Personal Information

Cancellation PolicyRequired

I agree to the cancellation policy

Cancellation Policy

◆Clinic Visit Notes◆

• · Please arrive 10 minutes before your appointment.
• · If you are more than 10 minutes late, it will be considered a same-day cancellation. In this case, counseling or treatment may not be possible, so please understand in advance.
• · If you wish to change or cancel your reservation, please contact us by 15:00 the day before your appointment.
• · If you cancel or change your time on the same day (after 15:00 the previous day) or are more than 10 minutes late on the day, you will be charged for one session. (For courses, one session will be consumed.)
• · For counseling only, same-day cancellations (after 15:00 the previous day) will incur a cancellation fee of 5,500 yen.

◆Treatment precautions◆

• · For women, if you are pregnant or breastfeeding, we may refuse treatment, so please inform us in advance.
• · If you have tanned within 3 months or plan to tan, you may not be able to receive treatment.
• · The use of acne medications (Epiduo Gel, Bepio Gel, Duac Gel, Differin Gel, etc.), hydroquinone, tretinoin, and retinol must be stopped 3 days before and after the treatment date.

Please understand that sudden cancellations or time changes make it difficult to accommodate other patients.
We aim to provide a comfortable time for each of you, so we appreciate your understanding and cooperation.

MY Beauty Clinic
Phone: 03-6228-5707
*Please contact the landline number above.