Online Medical Application - Men's Pride Clinic MITA TOKYO

Online Medical Application



    requiredEmail Address

    anypostal code


    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

    *Please select a payment method only for remote medical services.

    requiredWould you prefer ED (erectile dysfunction) treatment or AGA (alopecia) treatment?

    required01. do you currently have any medical conditions?

    If yes, please indicate the name of the disease

    required02. have you had any major illnesses in the past?

    If yes, please indicate the name of the disease

    required03. are you currently taking any medications?

    If you choose "Yes," please indicate the drug name

    required04. have you ever had an allergy (rash, redness, itching, etc.) to any medication?

    required05. do you have a heart condition (angina pectoris, myocardial infarction, etc.)?

    required06. do you use nitroglycerin or other blood pressure-lowering drugs for heart disease or other conditions?

    required07. do you have liver or kidney disease?

    required08. please answer about your blood pressure

    Please indicate if you have recently taken measurements.

    blood pressure

    Measurement period

    required09. have you ever had a cerebral infarction or hemorrhage?

    If you chose "Yes," please indicate when.

    required10. have you ever been diagnosed with retinitis pigmentosa?

    required11. do you have glaucoma? Do you also use eye drops for other eye diseases?

    required12. have you ever been diagnosed with a blood disease (reticulocytic anemia, multiple myeloma, leukemia, H I V, etc.)?

    required13. do you have any penile ailments (bends, lumps)?

    required14. have you ever used any of the following medications? Please ✓ the appropriate item(s). (Multiple answers allowed)

    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?

    any16. if you answered yes in #15 -> where was it prescribed?

    requiredHow did you hear about us? (How did you hear about us?)

    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.