Application Form

*Please fill in this form completely.

Name*

Gender*
Male Female

Age*

Phone or cell phone*

E-mail Address*

E-mail Address (Re-type)*

Your preferred date

*Please choose three dates except close day and operation day.
*Please note that your preferred appointment date may not be available.
*Since we prepare our schedule in advance, appointments will only be available for a date two days hence.
*Your appointment will be confirmed only when a member of our clinic staff contacts you by e-mail.

■close ■operation day

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1st choice*

2nd choice*

3rd choice*

Your correction procedure*
Glasses Hard contact lenses Toric contact lenses Soft contact lenses Nothing

Have you ever been examined in Minatomirai Eye Clinic?*
No Yes

Have you ever undergone refractive surgery in another medical center to correct myopia or hyperopia?*
No Yes

Content of inquiry