Name

Please write in the alphabet as it appears on your passport

Gender

As shown in passport: Please choose M, F, X

Date of birth

YYYY

Your email address

Your phone number

Country

(###)

###

####

Name of accommodation　

Note ⚠️ Please check with your accommodation in advance if it is possible to receive medical treatment in your room.

Accommodation website URL or phone number

(###)

###

####

Past medical history

If no, please write “none”.

Current medications

If no, please write “none”.

Medications you have had a bad reaction to (e.g., allergy, side effects)

If no, please write “none”.

Other symptoms　

If you have more than one symptom, please list them in (1), (2), and (3), and tell us when each began.

Please select the course

＜Pricing Plans＞ Plan A: Consultation + Prescription ¥45,000 Plan B: Consultation + Medication Provided ¥50,000 Plan C: Consultation + Medication Provided + Medical Certificate ¥55,000 ＜Referral to a Specialized Medical Institution＞ ⚠️ If the doctor determines that a referral to a specialized medical institution in Japan is necessary (e.g., for surgical procedures), a flat fee of ¥40,000 will be charged instead of the above three fixed-price plans. This includes the issuance of a referral letter. In such cases, we will not issue prescriptions or medical certificates. Please consult the referred medical institution for further care.

English Referral Letter

If you need an English medical referral letter for a specialized hospital (additional fee: ¥10,000) for further consultation after returning home, please let us know.

I would like to

I do not wish to

Other Requests / Questions

If you have any questions or concerns, please let us know here.

Medical interview

Contact us at

080-3462-8529

tokyoclinicjapan@gmail.com

TOKYO CLINIC