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BLEZ CLINIC at Asok > Request an Appointment

Request an Appointment

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

■Visited BLEZ CLINIC before?*
NoYes

■Full Name*(Alphabet)

■Daytime Phone*

■E-Mail address*

■Type of Consultation* Select from below ※Multiple answer
General MedicineChronic diseasesVitamin IVMedical checkupVarious certificatesSTI/STD checkupAllergy testOthers

■Remarks ※Please send an appointment form three days before your visit.
And please let us know what day and time you prefer.
OPENTIME:[Weekday]10:00〜14:00/15:00〜19:30 [Weekend]9:00〜14:00/15:00〜17:30
If you wish to make an appointment on that day or the next day, please call us directly.
EX. 01,July,2020 10:00am

By clicking on the button below, you declare your agreement

Agree

Response Time: We will reply within 48 hours for Appointment requests during this time. An auto-reply message 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 may be adjusted without any notice.

■If you have further questions or urgent issues, please contact the following telephone number.
English-Japanese 092-224-6972 (Mr. Kashimoto)