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Online Clinic Questionnaire
Please answer the questions below and send necessary pictures separately in e mail to Dr. Yumi Yamamoto.
Email address *
Q1. Your name on your Japanese Insurance Card/Alien Registration Card. *
Q2. Your address on your Japanese Insurance Card/Alien Registration Card. *
Q3. Do you have an allergy to any food or drug? If yes, please write what they are. *
Q4. What kind of problem do you want to discuss today? *
Q5. Have you already seen a doctor for this problem? If yes, what was the diagnosis and treatment you received? *
Q6. Do you have any medicine you take regularly besides your present problem, such as hypertension, hay fever? If yes, please write the name of your medicine and for what disease you are taking it. If possible, please send the picture of the medicine you take. *
Q7. Information of the pharmacy where you want to pick up your medicine; its name, address, tel number, and FAX NUMBER. *
Q8. Your phone number, which the clinic or the pharmacy may call if there is any problem. *
Q9. The prescription will be sent by fax to your nearby pharmacy after the confirmation of the charge payment. How do you want to pay the charge (1,500 JYN): through the bank (it takes one day or more before the confirmation), Amazon Gift Card (you can send the amount to from your Amazon account and the confirmation will be done in a few minutes), or another way? *
Q10. A short video conversation is required to identify yourself. Which tool do you want to use?
Clear selection
Q11. Can we send the receipt and the original prescription by post to the same address in Question 2? If no, please write the address where the postage should be sent.
Clear selection
Q12. Do you agree that answers of this questionnaire may be used for a public welfare medical study to improve Japanese medical service for foreigners under the pandemic or disasters. Your personal information will be protected according to the Japanese law. Even if you choose No in this answer, you can get the same care from the doctor.
Clear selection
After submitting this form, pictures of your Japanese Medical Insurance, Alien Registration Card, and your medicine (if you have) should be sent to The doctor will write to you from this address. Please make sure you set your mail account to receive an e-mail from this address. You can see the information of the doctor and the clinic here. *
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