Request an Appointment

Please be sure to read the notice about Covid-19 before making an appointment. >>>Notice

Please fill in the below form to request an appointment.
*required

    ■Visited BLEZ CLINIC before?*required
    NoYes

    ■Full Name*required

    ■Sex*required
    Mr.Ms.

    ■Daytime Phone

    ■E-Mail address*required

    ■Please attach a photocopy of your passport.*required

    ถ้าคนไทย กรุณาแนบรูปบัตรประชาชน

    ■Appointment Date & Time*required
    ,
    OPEN HOURS:
    [Weekday] 10:00 am〜02:00 pm／03:00 pm〜08:00 pm
    [Weekend] 09:00 am〜02:00 pm／03:00 pm〜06:00 pm
    [Lunch Break] 02:00 pm〜03:00 pm
    [Last Reception] 30 minutes before closing time

    ■Type of Consultation※Multiple answers*required
    Medical Certificate (Work Permit)Medical Certificate (Driving License)Medical Certificate (others)STI/STD Check-up (A)STI/STD Check-up (B)STI/STD Check-up (C)Immunization(Influenza)Immunization(Rabies)Immunization(Tetanus)Immunization(Hepatitis A+B)Immunization(Hepatitis A)Immunization(Hepatitis B)Immunization(Japanese Encephalitis)Immunization(Typhoid)Immunization(Chickenpox)Immunization(HPV/Cervical cancer)Medical Check-up(Basic)Medical Check-up(Basic Plus)Medical Check-up(Standard)Medical Check-up(Advance for over 40 men)Medical Check-up(Advance for over 40 women)Vitamin IV (Vitamin Boost)Vitamin IV (Anti-Melasma)Vitamin IV (Total Beauty)Vitamin IV (Boost Immune)Vitamin IV (Relax)General medicineOnline consultationAllergy Test

    ■Company Name, Address and Tax ID on your receipt if need

    ■Remarks

    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)