Online Reservation

Please fill out the form below with your desired date and time, and press the submit button.

You will hear from us within a few days after receiving an automated reply.

※If you do not receive a reply from us within 3 business days, please check your junk e-mail folders and set up your e-mail account to receive our messages.

※For an appointment on the day, please call us: 03-3569-1233.

name *

First

Middle

Last

Have you ever been to Le Coquelicot? *

• Yes
• No

mail *

Email

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Tel *

date Third preferable

First preferable date *

First preferable time *Time10:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:00

Second preferable date *

Second preferable time *Time10:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:00

　

Third preferable date

Third preferable timeTime10:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:00

Desired treatment (Maximum 500 characters) *

※For laser hair removal, please mention desired areas.
※For wart/mole removal, please mention the number of warts/moles that you would like to get removed.
※Please note that warts/moles on foot area cannot be treated at our clinic.

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