Initial Questionnaire - 2021
New Patients visiting the American Clinic Tokyo will be asked to fill out this questionnaire.
First Name, Middle Name(s)
Date of Birth
Prefer not to specify
Where are you currently located? Please be specific about location. This may allow us to expedite the appointment.
Emergency Contact (Phone Number)
What brings you here today? Please elaborate
Past Medical History (Diagnoses, operations, hospitalizations, accidents)?
Are you pregnant (Females only)?
Do you need a detailed itemized receipt? Please note that a Medical Summary of your visit will require an extra documentation fee.
Please check all that may apply.
General Practitioner / General Internal Medicine
As soon as possible
Morning hours (9:00-12:00)
Afternoon hours (15:00-18:00)
Out-of-hours (not listed here)
I (Legal representative of the applicant and as the representative parental guardian if the applicant is a minor and more than one guardian exists) hereby give consent to receive medical care at American Clinic Tokyo. I also authorize physicians, hospitals, and American Clinic Tokyo to release medical information and medical records to other parties when deemed necessary. I consent to receive treatment with imported medicine and dosage variations. I consent for medical photography and the use of the material to be used in teaching, education, research, and publication. I have read and understood American Clinic Tokyo’s financial policies and I accept responsibility for the payment of any fees associated with my care. I consent to communicate via the internet and I will not hold the American Clinic Tokyo responsible for unforeseen incidents that may happen during the communications. I hereby confirm that I have fully understood the risks and benefits of all of the above. My signature also authorizes the release of medical information necessary to pay my claim. Any dispute arising out of this medical encounter set forth above, the Tokyo District Court or the Tokyo Summary Court shall have the exclusive original jurisdiction. A photocopy or scanned document of this form shall be considered as effective and valid as the original. I hereby certify that the information above is complete and true to the best of my knowledge.
I agree and consent to the above.
Send me a copy of my responses.
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