Telemedicine Services Registration Form

*We will send you our telemedicine URL via SMS. If your phone cannot receive SMS, we will send it via E-mail. Please note that it may take 30 min for our e-mail message to be sent. For a quicker response, we recommend you register your mobile number that can receive SMS.

Full Name (exactly as written on your health insurance card)

Enter your patient ID number

Enter your date of birth

Month date Year

Select gender

Upload a photo of your Japanese health insurance card, or
Upload a photo of your passport or Japanese residence card, if you do not have an insurance card.

(Optional) Please upload a photo of your tongue (front) taken today if you are/likely to be a “long covid” patient or request a prescription of Eastern Herbal Medications for the first time at our clinic.

(Optional) Please upload a photo of your tongue (left or right) taken today if you request a prescription of Eastern Herbal Medications for the first time at our clinic.

Please enter your address

Mobile phone number (Number for SMS)

Enter telephone number we can call you on.

We will give you a call for ID verification after this form is sent. Must be Japanese phone (+81).

Enter your e-mail address

Enter pharmacy name where you intend to receive prescribed drugs

   *Please note that some types of medication cannot be shipped.

   * Your prescription will be sent via fax to the pharmacy right after your counselling with the doctor and payment. If the pharmacy is open, you can pick them up on the day.

( enter i. Pharmacy name, ii. address, iii. phone and fax number of the pharmacy )
Some pharmacies might reject pick-ups. To pre-check if your pharmacy can do pick-ups, please use the form below.

>>> Download Inquiry Form

Enter the pharmacy name

Enter telephone and FAX number of the pharmacy

Enter the pharmacy address

Medical History

Message to the Doctor

Please select either A or B below regarding our translation service during the telemedicine services.

However, I understand that the clinic medical translator may be appointed if the clinic deems it necessary to ensure the proficiency/accuracy of medical terms during telemedicine services.
I also understand that in the above case, I may be charged for the translation fee.