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For Your Smile, Sense Of Well-being.                                              日本語

Monday-Saturday:10:00-19:00/Close:Sunday・Holiday

4−25−1 Minami Aoya Minatoku Tokyo 107-0062  03-6427-2025

Cosmetic Acupuncture/Anti-Aging  Reservation Formreserve

*Please note that all fields followed by an asterisk must be filled in.

Name*
 E-mail*
 Phone number*  cell-phone home number
Address zip-code
information Birth: M D Y  
Age  nationality
Apoitment
Day & Time
First choice*
M D Day Time
Secound choice
M D Day Time
 Menu  
Medical History  Please fill in your history of condition in detail.
for example)
2005年(age 25) became a cold constitution
2013年(age 33) had shadows under eye and sagging skin


Did you you try any treatment for same condition before?
No Yes ()
Do you have any surgical history or chronic disease?
No Yes()
Do you take any medicine?
No Yes ()
Do you have any allergic?
No Yes()
  Do you have gastrointestinal discomfort? No Yes
Do you experience urinary frequency? No Yes
Do you have irregular eating habits? No Yes
Do you have a sleep-related problem? No Yes
An average menstrual cycle days
 Do you have a premenstrual syndrome? No Yes
  If Yes ()
Do you have a cold constitution? No Yes
 Remarks column
Question