Cosmetic Dermatology Elm Clinic
This site uses Google automatic translation. Our clinic staff cannot speak foreign languages. For inquiries, please send us a message using the contact form or LINE.

Reservation input form(Fukuoka-in)

Please configure your settings so that you can receive emails from the following domains.
If you do not receive a confirmation email after making a reservation, it may have arrived in your spam box.

@elm-clinic.jp
Name
Example) Hanako Yamada
Name (Hiragana)
Example) Hanako Yamada
Age/gender
Example) 30
Phone
Example: 080-0000-0000 *Please enter the area code in half-width characters.Also, please enter a hyphen.
Email
Example) xxx@elm-clinic.com
Preferred contact method
*If you do not receive the email,
　We may also give you a phone call.
Use of our hospital
Member No.
*For re-examination, please enter your member number below.
　Please fill in.
Details of reservation
Content of consultation
(Multiple possible)		 Trouble menu
Please write in as much detail as possible, including the desired part, machine, and symptoms of your concern.
*If you would like medical laser hair removal, men's hair removal, or permanent makeup, please select the content and area from the "Preferred menu" in the next section.
Desired menu
(Multiple possible)

If you have already received counseling or have decided on a treatment menu, please select the treatment name from here.
Medical laser hair removal (women)
Mens hair removal
Art makeup
Beauty injections & beauty drips
Medical equipment
Oral medicine & external medicine
Other
Requested date
(First choice)
Desired date
Please specify your desired time range.
Check the medical day calendar
Requested date
(First choice)
Desired date
Please specify your desired time range.
Requested date
(First choice)
Desired date
Please specify your desired time range.
Feel free to ask any questions
Please enter.

 
*If you are not sure what treatment to perform, please write down your concerns here.
*If you have a request from your doctor, please indicate so.
*If you would like to nominate a staff member other than a doctor, please indicate here (1 yen per time).Permanent makeup nomination fees are separate.

If you are a minor, a "parental consent form" is required.Please download it in advance, fill it out and bring it with you, or
Please be accompanied by one of your parents.

Terms of Service*Please read the terms of use before proceeding to the input confirmation screen.
Privacy Policy

Cosmetic Dermatology Elm Clinic has established the following information protection policy and strives to appropriately protect personal information so that patients can use our services with peace of mind.

[About collection and use of personal information]

Cosmetic Dermatology Elm Clinic has established the following information protection policy and strives to appropriately protect personal information so that patients can use our services with peace of mind.

[About collection and use of personal information]

Our clinic may ask patients to provide personal information.

  • Reservations for receiving treatment
  • Surveys, collecting customer requests and opinions regarding services
  • Other

We will acquire these information by proper and lawful means within the scope necessary for providing services to our customers, and use them for the provision and improvement of services and other legitimate purposes.In addition, the information will only be used within the scope of the purpose communicated to the patient in advance, and will not be used beyond that scope without the patient's consent.

*Your reservation will be completed as soon as you receive a reply from our clinic via email or phone. Responses will be sent on the same day from 10:00 to 18:30, and the next day if outside of that time.
*In the unlikely event that we do not receive your email, we may contact you by phone.Thank you for your understanding.

Cosmetic Dermatology Elm Clinic TOP / Clinic introduction / Fukuoka-in / Reservation