If you are foreign residents, we will ask to bring your foreign registration card or residence card.
Please note that we can not see you if you are illegal aliens.
please check the box on the form:Female or Male
Your home country＊
Kindly take a few minutes and fill out your home country.
Prefectural and city governments where you live now.
Please fill out if possible.
Do you have health insurance?(Include Japanese Health Insurances)＊
If you don't have any health insurance, We'll have to ask you to pay medical fee at your own expense.
If you checked ”Yes” in the above-question about the health insurance and you hope to use it ,would you please let us know about the kind of insurance?
If you checked ”Yes” in the above-question and you hope to use it ,it is compulsory input.
If possible , please enter your kind of health insurance.:e.g(Japanese health insurance,national health insurance or private insurance.)
If not ,there is no need to input.
Reading the above explanation about the doctor’s translation fee , could you consent ?＊
(e.g.for first 30 min we charge you 3,000JPN yen. After 30min, we charge you 1500JPN yen+ for every ten minutes . this is the case when you use Japanese health insurance.)
If you disagree, please choose ”No” , or cancel this form.
Do you hope to see the doctor in English?＊
If you choose ”Yes”, we'll ask you for doctor’s translation fee.
Do you agree with the above content?＊
When you can’t agree, please cancel to mention this application form.
Symptoms that you are suffering from....＊
Please check all that apply.
If you chose ”Others”, please write your symptoms at the comment field below in the clearest terms possible.
Do you hope to receive counseling treatment?＊
Please understand that according to Japanese Health Insurance Act, any kind of Japanese health insurances do not cover the counseling fee .(Till50min:¥8500yen)
How did you find this office?＊
You can choose multiple selection
Please enter the first visit date and time of the first request and the second request .＊
Please leave your message here. (e.g.:Your other symptoms or troubles that you are suffering from.)