氏名 / Your Name (required)

Eメール / Your Email (required)

住所 / Address (required)

生年月日 / Date of Birth (required)

電話番号 / Phone No (required)

携帯電話 / Mobile No

お仕事の電話 / Work Telephone


ご紹介者又はどのように当院をお知りになりましたか?
How did you hear about the practice?

現在服用中の薬名をお書きください。
Pharmaceutical Medications (Please list those you are currently taking)

主訴(つらい所はどこですか?いつ頃からですか?)
What is/are your main complaint(s)?

病歴(手術、病気、ケガ)
Medical history (Surgeries/Hospitalisation/Injuries)


INFORMED CONSENT FOR TREATMENT: Please read and agree to our terms conditions
治療への同意: 必ずお読みの上同意願います

I hereby request and consent to the performance of acupuncture treatment, massage treatment, manual therapy and other related procedures, including physical examinations, the use of acupuncture needles and modalities of heat (moxibustion), massage on myself (or the patient named below, for whom I am legally responsible).
Though treatments and therapies are usually beneficial and seldom cause any problems at all, I understand and am informed that as with any medical treatments there are risks involved.

鍼灸治療、マッサージ、徒手療法又はそれらに関連する身体検査を受けること、鍼や灸の使用に同意致します。またこれらの療法、治療は通常効果があり、健康に害を及ぼすものではありませんがリスクを伴うことを理解しました。