*

Request an Appointment

Please fill in the below form to request an appointment.
※Required fields

■Visited BLEZ CLINIC before?*
NoYes

■Full Name*(Alphabet)

■nationality*(Alphabet)

■Date of Birth*
B.C.

■Daytime Phone*

■E-Mail address*

■Type of Consultation* Select from below ※Multiple answer
General MedicinePediatricsChronic diseasesImmunizationBeauty& Boost immune IVMedical check-upVarious certificatesSTI/STD Check upOthers

■[Immunization ] Select immunization from below. ※Multiple answer
1.Hepatitis A2.Hepatitis B3. Rabies4.Tetanus5.Japanese Encephalitis6.Typhod7.HPV8. Yellow fever9.Influenza

■[Beauty & Boost Immune IV] Select IV from the list.

■[Medical Checkup Package] Select package from below.

■[STI/STD Check up] Select package from below.

■Preferred Appointment ※Please send appointment form three days before your visit.
OPNE[Weekday]10:00〜14:00/15:00〜19:00 [Weekend]9:00〜13:00/14:00〜17:00
If you wish to make an appointment on that day or next day, Please call us directly.
1st choice
2nd choice
3rd choice

■Any Allerrgies and Underlying diseases?
NoYesNot sure

■Remarks ※Details of underlying diseases, taking medicines and allergies

Clincking on the below button indicates agreement

Agree

Response Time: We will reply within 48 hours for Appointment requests during this time. An auto reply massage will be sent when we receive your requests. If you have not had any message from us, Please check your settings of mail receiver.

We appreciate your understanding that your requests maybe adjusted without any notice.

■If you have further questions or urgent issues, Contact following telephone number.
English-Japanese 092-224-6972 (Ms. Yoshida)