Customer’s Form

Thank you for visiting us. Please fill out the form below.






    RequiredPlease put a check mark in □ if any of these symptoms/conditions apply to you.

    RequiredHave a history of

    OptionalWhy did you decide to visit us?

    ・It is not contradicted for Cryotherapy the presence of any implants(silicon, intraosseous metal rods and plates).
    ・Please take off all accessories and metals(watch, body pierces) before the session.
    ・If your skin is wet with drops of water or sweat, wipe it off beforehand.
    ・If you have cream, lotion or oil on your skin, wipe it off beforehand.
    ・I was briefed about the risk of low-temperature burns during liquid nitrogen injection and sessions.