広尾プライム皮膚科
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　Patient Counseling Form

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

Name (Required) 　
Age (Required) 歳
Gender (Required)
Contact（Email） (Required)
Treatment Options
Pigmentation (Spots, Melasma, Discoloration)
Wrinkles & Sagging
Skin Quality Improvement & Anti-Aging
Hair Removal

Hair Treatments
Skincare
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 　
当日施術のご希望
当日の施術
【必須】当日施術のご希望
カウンセリング予約はこちら

0120-255-302診察時間:10:00-19:00