This form is to explain about general rule for patients to receive consultation and treatment at Sapporo Higashi Tokushukai Hospital. If you have any questions about the contents below, please feel free to ask anytime. If you do NOT agree after the explanation, you can still reject to receive consultation and treatment at Sapporo Higashi Tokushukai Hospital.

1. Hospitalization/frequent visit may be necessary depending on the results of your examination/procedure. Depending on the circumstances, you may need to transfer to a different hospital.
2. Your doctor or hospital staff will explain about the significance and the risks of the treatment to you each time. Please receive the treatment only when you agree with the explanation.
3. If you discontinue the treatment or fail to visit the hospital either on an outpatient and inpatient basis for your own reasons, you may suffer disadvantage from causing various risks such as treatment not appropriately performed or interference of issuance of a certificate or any other documents.

1. International patients who are not eligible to have a Japanese insurance will bear the full expenses.
2. Medical fee shall be paid without any delay as soon as your consultation is finished. When hospitalized, you will be asked to pay weekly.
3. Even in the event that you stop the treatment for your own reasons or diagnosis or　treatment is not as you expected, you are responsible for payment of all charges for services provided by the Hospital.
4. Treatment period may be prolonged due to unexpected complications or exacerbations. Patients are responsible for payment of all the expenses such as medical fee, accommodation fee and visa extension fee in that case.

1. We do not translate your medical record or data from previous hospital to Japanese in Sapporo Higashi Tokushukai Hospital.
2. If all the documents (data) required for consultation are not translated accurately, it may affect diagnostic accuracy in the hospital. Please understand that it may take more time and cost for additional examination in that case.
3. Our hospital has the employees for interpretation work from 8:30 to 17:00 on weekdays and 8:30 to 12:30 on Saturdays. However, due to the limited number, we may not be able to provide service of interpreter, in which case we have to use translating device, which may cause less effective communication. We kindly ask you to bring your own interpreter as much as possible.
4. Please be noted that when a patient’s family member (including minors), an acquaintance, or a relevant person serves as an interpreter and translates some critical information or other notification regarding the patient, it may impose a psychological burden on them.
5. The hospital is free from medical responsibilities under any circumstances such as misunderstanding or miscommunication through translators.
6. We may use the interpretation service by our employed interpreters or mobile devices when deemed necessary by the staff, even if the patient does not wish to use the service.

1. Your personal information provided for the treatment shall be kept confidential strictly as indicated in ”Regulations for Personal Information of Sapporo Higashi Tokushukai Hospital”; however, the hospital may disclose your medical information for cooperation with other medical facilities and nursing homes.

1. Please follow the instruction from hospital staff to keep social conventions and the hospital rules. Please also refrain from disturbing other patients or being a nuisance.
2. The official language of the consent forms, information sheets or any other documents, including this form, used in Sapporo Higashi Tokushukai Hospital is Japanese. In the event that a translation hereof is made in other languages, any such translation shall have no effect on the interpretation of the original.
3. The consent forms and information sheets used in Sapporo Higashi Tokushukai Hospital shall be governed by and construed in accordance with the law of Japan. Jurisdiction and venue for any claim or dispute arising from the service provided by Sapporo Higashi Tokushukai Hospital shall be subject to the exclusive jurisdiction of the Sapporo District Court in the first instance.