Customer Registration Form


For first-time visitors to our salon, we kindly request the completion of the "Customer Registration Form" in advance. Please input the following information and submit:


The personal information entrusted by our customers will be used solely as documentation for providing safe and effective treatments. It will not be used for any purposes other than the intended.

Reservation date
This registration sheet is not a reservation form.
If you have not confirmed your reservation, please do not register your customer information.
Reservation time
Name
Email Address
Gender
Do you have any infectious skin diseases or suspected infections on the scalp?　頭皮に感染性皮膚疾患またはその疑いはありますか?
Customers with infectious skin diseases on the scalp cannot receive treatment.
頭皮に感染性皮膚疾患がある方は施術をお受けいただけません。
Have you undergone treatment on yourDo you have a history of head or neck problems?　頭や首に既往歴はありますか？
Please provide details about current symptoms or considerations during treatment.　現在の症状や施術中に配慮する点などをご記入ください。
Do you have any allergies?　アレルギーはありますか？
Please specify the type of allergy.　アレルギーの種類を教えてください。
Please select the pressure intensity for shiatsu massage:　指圧の強さをお選びください
If you have any other requests or specific considerations during the treatment, please provide detailed information.　その他、ご要望や施術中に配慮して欲しい点があれば詳しくご記入ください。
個人情報取扱に関する同意
1. Name of organization that acquires personal information and administrator of personal information
Mimosa Co., Ltd.
Personal information protection manager　：　Junko Yokozeki
2. Purpose of use of personal information
Registration for application
3. If you have not entered your personal information
Entering personal information is optional, but if you do not enter it, we may not be able to provide you with smooth treatment information.
4. Acquisition of personal information by a method that cannot be easily recognized by the person in question
Communication in this form is encrypted.
5. Provision of personal information to third parties
Unless we have your consent or are required by law, we will not provide the personal information you enter to any third party.
6. Entrustment of personal information
When entrusting the handling of personal information to a third party, we will select a third party that has a system to appropriately protect personal information, and the organization entrusted with the handling of personal information will appropriately supervise the third party. .
7. Requests regarding personal information, etc.
We will respond appropriately to requests for disclosure, correction, suspension of use, etc. of personal information by the individual without delay after confirming the identity of the individual. Please note that by suspending or deleting your personal information, you may no longer be able to use Mimosa Co., Ltd.'s services.
8. Contact information
Mimosa Co., Ltd.
email ：mimossa@kyi.biglobe.ne.jp　
address：1-6-6 Ginza, Chuo-ku, Tokyo
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