■ Last name　
　■ First name　

　■ Email address　

　■ Tel＃　

　■ Preferred date and time ex：18：00
　　 　1st ： Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 　　　Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 　　 Time
　　 　2nd ： Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 　　　Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 　　 Time
　<Opening Times> 10:00 - 21:00　　　　　　　　　　　　 　　　 　　　　　　　　　
　■ Preferred course　 ▽Please select Body 60mins Body 75mins Body 90mins Facial 70mins Facial&Body120mins
　■ Your purpose of treatment is　 ▽Please select Relaxation Healtcare Interest for aromatherapy

　■ How did you know "plus A"?　 ▽Please select Internet search Flier Your friend's recommendation

　■ I will send you the map from Ebisu and Hiroo station
　　　 by email (PDF file) or fax
　　　　　　　　　　　　　　　 Your preference ▽Please select Email FAX

　　＊ If you prefer to receive by FAX　＃
　
　■ Enquiries or message, if any.