　Patient Counseling Form

For international patients.
Please fill out the form below in English.

Name (Required)	Last Name 　First Name
Age (Required)
Gender (Required)
Contact（Email） (Required)
Treatment Options	・Pigmentation (Spots, Melasma, Discoloration) Pico Laser IPL ・Wrinkles & Sagging Btox　　　 HIFU　 Hyaluronic Acid ・Skin Quality Improvement & Anti-Aging Mesotherapy Skin Rejuvenation Injections (Rejuran / Sunekos / Profhilo) ・Hair Removal Body Hair Removal Please specify desired area(s) 　・Hair Treatments Mesotherapy ・Skincare Skincare Consultation Professional Skincare Guidance ・Other Concerns / Consultations
Appointment Request (Required)	Preferred Date & Time Please specify your preferred date and time (e.g., MM/DD, morning/afternoon).Note: The appointment date must be at least one week from today. 1st Choice 　　 2nd Choice
Treatment on the day of visit (Required)	Would you like to receive the treatment on the day of your visit? Yes No

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