【Minato-ku, Tokyo】 6 minutes walk from Hamamatsucho Station, 3 minutes walk from Takeshiba Station

Four Seasons Cosmetic Dermatology Clinic フォーシーズンズ東京院 / Four Seasons Cosmetic Dermatology Clinic / 四季 皮肤美容诊所

Web Medical Questionnaire

Web Medical Questionnaire

Customers who request telephone consultation on the counseling reservation page need to fill out this questioinnaire.
If you have not yet made a consultation reservation, please make one from the link below.

Click here to reserve a consultation


Web Medical Questionnaire

*If you would like telephone consultation, please submit this web questionnaire.

*All fields are required.

Date of birth
Year Month Day
years old
Post code
Telephone number
Email address
Your profession
Weight (0.5kg increments)
Height (0.5cm increments)

At our clinic, we aim to provide natural rejuvenation and skin beautification treatment for people between the ages of 5 and 28.

Area of concern 1
Do you have any concerns other than those listed above?
When did you start to notice it?
year ago,
months ago,
Have you ever received treatment for the above concerns?
How much rejuvenation do you want?
*This question is related to the realm of natural rejuvenation.
How much do you want your skin to be beautiful?
Are there any events coming up soon?
*Parties, reunions, visiting days, girls' nights out, family gatherings

*We will suggest the best treatment so that you can enjoy these event even more.
What do you see in others (classmates, celebrities, etc.) that you find youthful or beautiful? (Multiple selections possible)
Please check the treatment you are interested in (multiple selections possible)
Do you currently have any illness or are undergoing treatment?
Are you currently taking any medications?
Have you ever had an allergy to medicine, food, or alcohol?
Have you ever been diagnosed with anemia or low hemoglobin?
Are you currently pregnant or potentially pregnant?
Are there any metal objects such as plates or bolts, gold thread, or silicone inserted into your body?
Are there any scars or bruises on your body?
Do you have any experience in receiving treatment at a beauty clinic?
Do you have any tattoos on your body?
Please tell us your skin type
Please tell us about the triggers lead you came to our clinic.
Please tell us about the skin you want and your ideal skin condition.
Would it be okay for our clinic to contact you via DM, etc.?