Appointment

meclogoMinamiaoyama Eye Clinic Application Form

      • Your appointment will be confirmed only when a member of our clinic staff contacts you by e-mail.
      • It takes a couple of days to reply your E-mail. Please call us if you have any urgent request.
      • This appointment form is for pre-surgical examinations only.
        For all other appointments, please make your appointment here.
      • Currently, appointments are fully booked. Please schedule your appointment for a date at least three weeks from now.

    Consultation content*


    What is the reason for consultation?

    First&Last name*

    Phone or cell phone*

    E-mail Address*

    E-mail Address（Re-type）*

    Gender*
    MaleFemale

    Age*

    ※Clinic close on Tuesday and Monday holiday .Currently, appointments are fully booked. Please schedule your appointment for a date at least three weeks from now.

    1st choice*

    2nd choice*

    3rd choice*

    If there is an emergency, please call us.(03-6633-4872)

    Reservation must be notified a few days in advance.


    Your correction procedure*
    GlassesSoft contact lensesHard contact lensesNothing

    Your past visits*
    YesNo

    Patient ID(Identification) card number

    Past history(e.g.LASIK)*
    YesNo


    Content of inquiry

    Notes

    • If there is no reply even 10minutes or more, please call us(03-6633-4872).
      （9:30～18:00　clinic close on Tuesday and Monday of National holiday）
    • It takes about 2 hours for surgery examination and consultation.
    • We will put some medicine in your eyes to open your iris.
      Please do not come to our clinic by car.
    • The examination charge for the ReLEx SMILE, LASIK, and ICL is Free. Orthokeratorogy, we charge 3,000JPY for the examination. The rental charge for the trial lens is free.
    • The consultation charge (pre LASIK/SMILE/ICL/Orthokeratology) for the patients who could NOT speak English or Japanese will be 20,000 JPY.

    • We will charge 20,000 JPY for the second opinion in the patients who received refractive surgery (LASIK, ICL, etc).

    ※Minors must be accompanied by an adult.