RESERVATION

※Regarding your desired appointment date, our staff will contact you to confirm. Please note that your appointment will be finalized upon this confirmation.

For minors receiving treatment, consent from a legal guardian (parent or legal representative) is always required. Therefore, either the legal guardian (parent or legal representative) must accompany the minor during the consultation, or a written consent form signed by the guardian is mandatory. When minors undergo treatment, we may contact the legal guardian (parent or legal representative) by phone for verification. We kindly ask for your understanding and cooperation in this matter.

Download Parental Consent Form(Japanese Only)

    Please select one option.Required

    Select a treatmentRequired

    Please select an appointment date and time.Required

    First choice

    Date

    Time

    Second choice

    Date

    Time

    Would you like to receive treatment on the day of your visit?

    Your nameRequired

    Phone numberRequired

    Once your counseling appointment date and time are confirmed, we will contact you by phone. Please enter your information accurately. *Mobile phones are acceptable.

    Email addressRequired

    ※Mobile email addresses are also acceptable.

    ※If you have domain restrictions, please add “osaka@revios.jp” to your allowed sender list beforehand.

    Date of BirthRequired

    Year
    Month
    Day

    Your ageRequired

    years old

    ※Selecting your birthdate correctly will automatically input your age.

    Remarks

    Please enter any other requests you may have.

    We will contact you by phone or email regarding your appointment date and time.
    If you absolutely prefer email, please write “Email preferred” in the remarks section.
    *Please note that contact may be delayed on clinic holidays.
    *For appointment changes or cancellations, please be sure to contact us by phone during business hours the day before.
    *Customers who repeatedly cancel on the day of their appointment without notice may be refused entry without prior warning.

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    ＜Handling of Personal Information＞

    We strictly manage the personal information provided by our customers and will not disclose or provide it to any third parties without your consent.
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