For a free Examination booking or Enquiry
Please provide the information requested below to book a free consultation and eye examination at our Shinjuku LASIK Center. If you have any questions regarding our services, please state your questions or comments in the space below.

English services are available at the clinic in Tokyo ONLY.
For patients visiting clinics outside of Tokyo, please understand that medical treatments are technical and Shinagawa LASK Center focuses on safety first. Therefore our clinic may decline any services and/or treatment, if the patient cannot communicate in fluent Japanese or is not accompanied by a Japanese interpreter.

Please read the following information before completing and sending the form

※Please check your email settings to ensure that our clinic's email is not blocked and reaches your mailbox.
・Emails from the Shinagawa LASIK Center may be in your junk folder.
・Our clinic's email will be shown as
・Please be patient and allow up to 3 days for our staff reply to your enquiries.
・Some answers/replies may need to be reviewed with our doctors.
・In case of urgency, please feel free to contact our staff at 080-8867-4964.


Please understand that not all people are suitable for refractive treatment.
Our clinic may not be able treat those with the following: history of current health conditions, medication,
over 70 yrs old, currently pregnant or nursing:
◎ Medical History
High blood pressure, diabetes, asthma, epilepsy, obesity (over BMI of 30), heart disease
◎Current medication
Steroids, immunosuppressant drugs, anticoagulants or antiplatelet medication (prevents blood clotting) .
・Please be aware that some treatments on the website may not be available at the Sapporo, Nagoya, Umeda and Fukuoka clinics.
・The scheduling of your booking request will depend on the availability of staff and doctors at our clinics.
・Regarding the examination date and time, please check your emails thoroughly as our staff will contact you to verify the appointment within 24-48 hours.
・The examination and consultation will take about 3 to 3.5 hours.
・A pupil dilation will be required during the examination, therefore please avoid driving or riding a bicycle on the day of the examination.
・Pregnancy: If you are currently pregnant or nursing, you may not be able to undergo a treatment in the near future. Please contact our staff for details.

[1 day LASIK]
If you are interested in undergoing an examination and treatment on the same day you will be required to undergo the examination in the morning and the treatment will be performed in the later in the afternoon.
If interested, please state "1 day LASIK" in the comments section.

For Contact Lens Users:

To ensure safety and to collect accurate data for the eye examinations, please follow the correct guideline for the type of contact lenses you are currently using.

Please provide the requested information below and click 「submit」

family name

given name

Katakana (if possible)

Phone number
  • -
  • -

(Please retype the same email twice for confirmation)

Date of Birth (Year/Month/Date)
  • year
  • month
  • date

First choice of date & time for examination
  • year
  • month
  • date
  • time
Second choice of date & time for examination
  • year
  • month
  • date
  • time
Preference of location

Questions or comments

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