Fill out the form below and click "submit". First Name Last Name Email Address Are you already a registered patient of Tokyo Skin Clinic? yes — enter your ID number here: You can skip the next block of questions. yes, but I forgot my ID number no Please continue to the next block of questions. Not necessary to fill out if you have your ID number Sex select female male non-binary Age years Place of residence (country, municipality) Postal Code Telephone Main problem you wish to see a doctor about: Was our clinic recommended to you by one of our patients? If yes, name of the patient: Give three preferences after checking the days the clinic is open on the web calendar. Please choose dates within three months from today. First Preference month January February March April May June July August September October November December day 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st day of week and time Monday 2:00 or 2:30 pm Monday 3:00 or 3:30 pm Monday 4:00 or 4:30 pm Monday 5:00 or 5:30 pm Monday 6:00 or 6:30 pm Tuesday 9:00 or 9:30 am Tuesday 10:00 or 10:30 am Tuesday 11:00 or 11:30 am Tuesday 12:00 or 12:30 pm Tuesday 1:00 or 1:30 pm Wednesday 2:00 or 2:30 pm Wednesday 3:00 or 3:30 pm Wednesday 4:00 or 4:30 pm Wednesday 5:00 or 5:30 pm Wednesday 6:00 or 6:30 pm Thursday 9:00 or 9:30 am Thursday 10:00 or 10:30 am Thursday 11:00 or 11:30 am Thursday 12:00 or 12:30 pm Thursday 1:00 or 1:30 pm Friday 2:00 or 2:30 pm Friday 3:00 or 3:30 pm Friday 4:00 or 4:30 pm Friday 5:00 or 5:30 pm Friday 6:00 or 6:30 pm Saturday 9:00 or 9:30 am Saturday 10:00 or 10:30 am Saturday 11:00 or 11:30 am Saturday 12:00 or 12:30 pm Saturday 1:00 or 1:30 pm option preferably earlier time preferably later time Second Preference month January February March April May June July August September October November December day 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st day of week and time Monday 2:00 or 2:30 pm Monday 3:00 or 3:30 pm Monday 4:00 or 4:30 pm Monday 5:00 or 5:30 pm Monday 6:00 or 6:30 pm Tuesday 9:00 or 9:30 am Tuesday 10:00 or 10:30 am Tuesday 11:00 or 11:30 am Tuesday 12:00 or 12:30 pm Tuesday 1:00 or 1:30 pm Wednesday 2:00 or 2:30 pm Wednesday 3:00 or 3:30 pm Wednesday 4:00 or 4:30 pm Wednesday 5:00 or 5:30 pm Wednesday 6:00 or 6:30 pm Thursday 9:00 or 9:30 am Thursday 10:00 or 10:30 am Thursday 11:00 or 11:30 am Thursday 12:00 or 12:30 pm Thursday 1:00 or 1:30 pm Friday 2:00 or 2:30 pm Friday 3:00 or 3:30 pm Friday 4:00 or 4:30 pm Friday 5:00 or 5:30 pm Friday 6:00 or 6:30 pm Saturday 9:00 or 9:30 am Saturday 10:00 or 10:30 am Saturday 11:00 or 11:30 am Saturday 12:00 or 12:30 pm Saturday 1:00 or 1:30 pm option preferably earlier time preferably later time Third Preference month January February March April May June July August September October November December day 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st day of week and time Monday 2:00 or 2:30 pm Monday 3:00 or 3:30 pm Monday 4:00 or 4:30 pm Monday 5:00 or 5:30 pm Monday 6:00 or 6:30 pm Tuesday 9:00 or 9:30 am Tuesday 10:00 or 10:30 am Tuesday 11:00 or 11:30 am Tuesday 12:00 or 12:30 pm Tuesday 1:00 or 1:30 pm Wednesday 2:00 or 2:30 pm Wednesday 3:00 or 3:30 pm Wednesday 4:00 or 4:30 pm Wednesday 5:00 or 5:30 pm Wednesday 6:00 or 6:30 pm Thursday 9:00 or 9:30 am Thursday 10:00 or 10:30 am Thursday 11:00 or 11:30 am Thursday 12:00 or 12:30 pm Thursday 1:00 or 1:30 pm Friday 2:00 or 2:30 pm Friday 3:00 or 3:30 pm Friday 4:00 or 4:30 pm Friday 5:00 or 5:30 pm Friday 6:00 or 6:30 pm Saturday 9:00 or 9:30 am Saturday 10:00 or 10:30 am Saturday 11:00 or 11:30 am Saturday 12:00 or 12:30 pm Saturday 1:00 or 1:30 pm option preferably earlier time preferably later time Do you wish to undergo a procedure or a laboratory test? procedure (specify): laboratory test (specify):