MY Beauty Clinic Ginza Cosmetic dermatology, medical slimming, plastic surgery

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【Vaccine Application at MY Beauty Clinic】
Location: 4th floor, RBM Ginza Building, 7-4-15 Ginza, Chuo-ku, Tokyo
Access: 4-minute walk from Ginza Station (Tokyo Metro Ginza Line, Marunouchi Line, Hibiya Line) B7C3 Exit

Please fill out the following items and press “Confirm input”.

Patient Information

Japan

NameRequired	First Name Last Name
GenderRequired	Male Female
Date of BirthRequired	・For high school students, a guardian must accompany them for the vaccination. ・Vaccinations for junior high school students and younger are not available due to the absence of a pediatrician.
Postal CodeRequired	〒 -
PrefectureRequired
CityRequired
Town and StreetRequired
Phone NumberRequired	e.g., 03-0000-0000
Email AddressRequired	Please re-enter for confirmation.
Do you have previous visit history?Required	Yes No
Patient ID (if known)Optional

Vaccine Information

DestinationRequired
Purpose of TravelRequired	e.g., assignment, study abroad, travel, etc.
Travel Start DateRequired
Travel End DateRequired
Preferred Visit DateRequired	Please specify your preferred date and time at least one week from the provisional application date. First Preference Second Preference Third Preference Please avoid the time between 14:00 and 15:00 as it is a break time. Please avoid Mondays and Tuesdays as they are closed days.
Desired Vaccine or TestRequired*Multiple selections allowed	Vaccine Rabies Vaccine(19,800 yen per dose) Tetanus Vaccine(4,840 yen per dose) Japanese Encephalitis Vaccine(8,250 yen per dose) Hepatitis A Vaccine(9,900 yen per dose) Hepatitis B Vaccine(4,950 yen per dose) Typhoid Vaccine(11,000 yen per dose) MR (Measles-Rubella) Vaccine(10,780 yen per dose) Meningitis Vaccine(25,300 yen per dose) DTP Vaccine (Diphtheria Pertussis Tetanus Polio)(14,300 yen per dose) Out of stock Varicella-Zoster Vaccine(9,900 yen per dose) Mumps Vaccine(6,600 yen per dose) Pneumococcal Vaccine(9,350 yen per dose) Polio Vaccine(7,700 yen per dose) Gardasil 9(single dose 38,500 yen) Gardasil 9(three doses 110,000 yen) Silgard 9(single dose 44,000 yen) 3-in-1 Tdap (Diphtheria, Pertussis, Tetanus) Vaccine(14,960 yen per dose) 3-in-1 DTP (Diphtheria, Pertussis, Tetanus) Vaccine (4 950 yen per dose)(4,950 yen per dose) High-Altitude Sickness Prevention Medication Diamox Rubella Antibody Test 【 Fully subsidized by Shibuya Ward 】 Rubella Antibody Test MR Vaccine 【 Coupon 】Please confirm in advance whether you are eligible for the Shibuya Ward Rubella Antibody Test. Also the fully subsidized MR Vaccine in Shibuya Ward is only available to those with an HI method result of 16 times or less. Malaria Prevention Medication Malarone Self-Pay Test Measles Antibody Test (4,070 yen) Rubella Antibody Test (4,070 yen) Measles-Rubella Antibody Test (4,840 yen) Varicella Antibody Test (4,070 yen) Mumps Antibody Test (4,070 yen) Hepatitis B Antigen-Antibody Test (3,850 yen) Infectious Disease Test Self-Pay Test Undecided (Please specify in the remarks.)
Vaccination History at Other ClinicsRequired	Please specify the types and dates of vaccines received at other clinics. *If you have received or plan to receive the COVID-19 vaccine within one month, please be sure to enter it. e.g., Hepatitis A (1st dose) January 1, 2018
Confirmation of Vaccination IntervalRequired	Did you receive the COVID-19 vaccine within the last two weeks? Received Not received
Vaccination Certificate RequestRequired	If you wish to request an English certificate, please select a date at least five days after the application date. Depending on the contents of the certificate, we may need to check if we can issue it, so please confirm the required sections with the issuing authority and share them via fax in advance. Please allow a few days for the issuance. Yes (Clinic Format) 【Japanese】 (3,300 yen) Yes (Copy of Medical Questionnaire) 【Japanese】 Yes (Clinic Format) 【English】 (5,500 yen) Yes (Other Format) 【English】 (5,500 yen) *Pre-consultation required No
Vaccination Certificate Format UploadOptional	If you have a specified format for the vaccination certificate, please upload it. ×
Mother and Child Health Handbook UploadRequired	Mother and Child Health Handbook Upload Do not have a Mother and Child Health Handbook Please upload the vaccination record page of your Mother and Child Health Handbook. ×
RemarksOptional	If there are any other necessary documents, please specify.

Confirmation Items

How did you learn about our clinic?Required	From a Company From a Health Insurance Association Search Engine (Yahoo! Google) Have undergone a health checkup Have visited outpatient services TikTok Twitter Instagram Facebook Official LINE Other SNS From a Friend Other
Personal InformationRequired	Agree to the handling of personal information About the handling of personal information

Inquiries & Reservations

Please feel free to contact us.

Reception Hours: 10:00~18:00 03-6228-5707

We are available 24 hoursLINE Reservation Here

We are available 24 hoursCounseling Reservation Here

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