Online Medical Application

Repeat visitClick here for medical examinations

requiredidentity
requiredfurigana
requiredEmail Address
anypostal code	mail
requiredaddress (e.g. of house)
requiredDate of birth (Year Month Day)
requiredPhone number
anyPreferred consultation date and time It would be very helpful if you could give us about 3 items.	first choice second choice third choice
requiredDiagnosis and Treatment	remote medical examinationvisit to a hospital, temple, school, etc. *Please select a payment method only for remote medical services. Credit card payment (Visa and Master only)bank transferCOD
requiredWould you prefer ED (erectile dysfunction) treatment or AGA (alopecia) treatment?	EDAGAboth
required01. do you currently have any medical conditions?	Yes, sir.No, sir. If yes, please indicate the name of the disease
required02. have you had any major illnesses in the past?	Yes, sir.No, sir. If yes, please indicate the name of the disease
required03. are you currently taking any medications?	Yes, sir.No, sir. If you choose "Yes," please indicate the drug name
required04. have you ever had an allergy (rash, redness, itching, etc.) to any medication?	Yes, sir.No, sir.
required05. do you have a heart condition (angina pectoris, myocardial infarction, etc.)?	Yes, sir.No, sir.
required06. do you use nitroglycerin or other blood pressure-lowering drugs for heart disease or other conditions?	Yes, sir.No, sir.
required07. do you have liver or kidney disease?	Yes, sir.No, sir.
required08. please answer about your blood pressure	usuallylow blood pressurehigh blood pressure Please indicate if you have recently taken measurements. blood pressure Measurement period
required09. have you ever had a cerebral infarction or hemorrhage?	Yes, sir.No, sir. If you chose "Yes," please indicate when.
required10. have you ever been diagnosed with retinitis pigmentosa?	Yes, sir.No, sir.
required11. do you have glaucoma? Do you also use eye drops for other eye diseases?	Yes, sir.No, sir.
required12. have you ever been diagnosed with a blood disease (reticulocytic anemia, multiple myeloma, leukemia, H I V, etc.)?	Yes, sir.No, sir.
required13. do you have any penile ailments (bends, lumps)?	Yes, sir.No, sir.
required14. have you ever used any of the following medications? Please ✓ the appropriate item(s). (Multiple answers allowed)	ViagralevitraCialispropeciaNever used. If you have used it, please indicate when you used it
any15. if you answered that it is #14 -> was it prescribed by a hospital or clinic?	Yes, sir.No, sir.
any16. if you answered yes in #15 -> where was it prescribed?
requiredHow did you hear about us? （How did you hear about us?)	Google (WWW search engine)YAHOOOther MediabillboardBuilding SignageIntroduction by an acquaintanceOther If other, please fill in

Consent form for prescribing drugs to treat erectile dysfunction or alopecia

Hayashi Bldg. 7F, 5-32-3 Shiba, Minato-ku, Tokyo 108-0014, Japan Men's Pride Clinic MITA TOKYO

I agree to provide information about all oral medications and pre-existing medical conditions, to abide by my physician's instructions, and to receive a prescription for erectile dysfunction or alopecia medications in compliance with the following
01. provided information on all previous medical history, oral medication history, hospitalization history, etc.
02. no history of cardiac disease (especially angina pectoris or myocardial infarction).
03. no nitroglycerin or other nitrates are currently being used.
04. partner also consents to the use of erectile dysfunction drugs.
05. also understood the side effects of erectile dysfunction drugs or alopecia drugs.
06. if any adverse reaction occurs, discontinue use and contact us immediately.
07. will not give or sell erectile dysfunction or alopecia treatments to others.
08. do not use erectile dysfunction or alopecia treatments beyond the prescribed dosage.
09. when visiting other health care providers, provide that the patient is taking medication to treat erectile dysfunction or alopecia.
If various examinations indicate that the patient is unable to use the erectile dysfunction treatment or alopecia treatment, the erectile dysfunction treatment or alopecia treatment should be discarded in accordance with the physician's instructions.

requiredI agree to the above contents.