Patient Form

    requiredSurname

    anyMiddle name

    requiredFirst name

    requiredYour gender

    requiredYour date of birth



    requiredYour nationality

    requiredYour email address

    anyYour phone number

    requiredWhere are you currently located

    requiredWhat is your primary language

    requiredIs an English consultation suitable for you?

    requiredDo you have any health care insurance?

    requiredWhat health issue or symptoms

    are you experiencing?

    requiredDo you have any chronic or

    pre-existing medical conditions？

    requiredAre you currently taking any medications?

    anyIf yes, please provide details

    required Do you have any allergies

    to medications or other substances?

    anyDo you smoke, drink alcohol,

    or use other substances?

    anyIf so, how often?

    anyHave you recently traveled

    outside of Japan or arrived from abroad?

    anyif yes, when and where did you travel?

    requiredWhat is your preferred day

    for the consultation?(First preference)

    Please select from the options below

    requiredWhat is your preferred time?(First preference)

    requiredWhat is your preferred day

    for the consultation?(Second preference)

    Please select from the options below

    requiredWhat is your preferred time?(Second preference)

    requiredWhat is your preferred day

    for the consultation?(Third preference)

    Please select from the options below

    requiredWhat is your preferred time?(Third preference)

    anymessage

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