Online Reservation — Medical Weight Loss

Telemedicine Consent (Ikegawa Clinic — International Patients)

1. I understand this is an online medical consultation conducted via Google Meet, and that my doctor is licensed under Japanese medical law.
2. I consent to identity verification via passport image.
3. Booking Fee & Cancellation Policy:
   • The booking fee of JPY 1,000 paid at the time of reservation will be fully credited against my total medical bill (consultation fee + medication cost) after the appointment. It is effectively a prepayment, not an extra charge.
   • I may cancel my reservation free of charge until 23:59 JST on the day BEFORE my appointment. The booking fee will be refunded in this case.
   • If I cancel on the day of the appointment or do not show up (no-show), a JPY 5,000 cancellation fee will be charged to my saved card, and the booking fee will not be refunded.
4. Fees after the consultation:
   • In addition to the medication cost, an International Patient Consultation Fee of JPY 5,500 will be charged. This fee includes the issuance of a medical certificate / prescription document required for international travel with the medication.
   • The medication cost depends on the prescribed dose and quantity, and will be communicated during the consultation.
   • Total amount = consultation fee (JPY 5,500) + medication cost − booking fee (JPY 1,000 already paid).
   • Follow-up visits within 3 months of your previous consultation: the JPY 5,500 consultation fee is not charged. In that case, Total amount = medication cost − booking fee (JPY 1,000 already paid).
5. I consent to my card information being securely saved (via Square) for automatic billing of the consultation fee and medication cost after the appointment.
   • Unless I request otherwise, the registered consultation fee and medication cost will be automatically charged to my saved card when the consultation is completed.
   • If I notify the clinic during the consultation, I may change the credit card used for payment.
   • If a payment has already been completed and I subsequently change the card to be charged, a fee associated with the refund process may apply.
6. Side Effects & Self-Responsibility (IMPORTANT for overseas residents):
   • Mounjaro / Wegovy are GLP-1 / GIP receptor agonists, with possible side effects including nausea, vomiting, constipation, diarrhea, fatigue, injection site reactions, hypoglycemia, gallbladder problems, and rarely pancreatitis or severe allergic reactions.
   • I understand that Ikegawa Clinic is located in Japan and CANNOT provide emergency in-person medical care to patients residing or traveling abroad.
   • If side effects or other medical problems occur outside Japan, I take full responsibility for seeking local medical care. Ikegawa Clinic shall NOT be held liable for any harm, complications, or damages arising from the use of the prescribed medication while I am outside Japan.
   • I will report severe symptoms (e.g., severe abdominal pain, difficulty breathing, severe allergic reaction) to the nearest local emergency services immediately, then notify Ikegawa Clinic via LINE.
7. Shipping & Refrigerated Delivery:
   • Medications can only be shipped to addresses within Japan (hotel during my stay, friend / family member's residence). International shipping is not provided.
   • Mounjaro / Wegovy require refrigerated (cool) delivery. If using a hotel address, I will confirm in advance with the hotel that they can accept and store refrigerated packages on my behalf.
   • If the package is refused, returned to sender, or spoiled because the recipient (hotel or otherwise) cannot accept refrigerated delivery, Ikegawa Clinic is NOT responsible. Re-shipping fees and the cost of any spoiled medication will be borne by me.
8. I consent to my personal medical data (including passport image) being stored in compliance with Japanese privacy law.
9. I understand all communication with the clinic is conducted via the Official LINE account. The clinic does NOT make phone calls to overseas numbers.