Medical interview Name * Please write in the alphabet as it appears on your passport Gender * As shown in passport: Please choose M, F, X M F X Date of birth * MM DD 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 * (###) ### #### Approximate weight (Kg) * If unknown, please write “Unknown” 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”. Current Symptoms * Chest pain Difficulty breathing, Dyspnea Loss of consciousness Major injury Fever Cough Phlegm Sore throat Nausea Vomiting Stomac ache Abdominal pain Diarrhea Headache Other Symptoms 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 ¥50,000 Plan B: Consultation + Medication Provided ¥60,000 Plan C: Consultation + Medication Provided + Medical Certificate ¥70,000 ＜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 ¥50,000 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. A Medical treatment Prescription B Medical examination, delivery of medicine C Clinical examination, delivery of medicine, medical certificate 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. Thank you for filling out the medical interview form.The doctor will send you an email with their estimated time of arrival at your accommodation. Contact us at 080-3462-8529tokyoclinicjapan@gmail.com TOKYO CLINIC
