Termination Consultation
日本語 English
Step 1 / 8 Basic Info
📋

Pregnancy Termination Consultation

Please read the important information below before completing the questionnaire.

Important Information — Please Read Carefully

  1. We perform medication-induced abortion up to 8 weeks of gestation.
  2. Depending on gestational age, comorbidities, current medications, supplements, and age (under 18 or over 40 years), we may not be able to provide this service.
  3. Patients must reside within 16 km of our clinic (approximately 30 minutes by car).
  4. Eligibility for our service will be determined after outpatient examination.
  5. Initial examination costs approximately 20,000 JPY, and the procedure costs approximately 110,000 to 130,000 JPY.
  6. Detailed information will be provided after consultation.

About This Questionnaire

  • This will take approximately 5-10 minutes
  • All items are optional, but complete answers help us provide safer care
  • Your data is kept strictly confidential and processed only in your browser (not sent until you submit)
01

Basic Information

Please provide your name and contact information

Age: －
Please note any preferences regarding callbacks in the free-text field
Distance from our clinic affects eligibility (within 16 km required)
cm kg
BMI: －
02

Visit History & Pregnancy Status

Please complete to the best of your knowledge

Pregnancy Status

Estimated gestational age: －
⚠ If you have heavy vaginal bleeding, severe abdominal pain, or a fever above 38°C, please seek medical care promptly.
03

Menstrual & Pregnancy History

Please complete to the best of your knowledge

Menstrual History

years
★ The cycle is the number of days from the start of one period to the start of the next period
Period Days until the next period Period Start of previous period Start of next period This is the "menstrual cycle" (e.g., 28-day cycle)
If your cycle varies, please indicate the shortest and longest cycle length.
If your cycle is about the same each month, enter the same number in both fields.
days
days
days

Pregnancy & Delivery History

(G)
(P)
times
Medically important for safe care
04

Medical History, Medications & Surgeries

Comorbidities and medications may affect eligibility for our service

Comorbidities are important for determining eligibility for our service
Past uterine surgery is particularly important
Certain medications may make our service unavailable for you
Some supplements may affect eligibility
05

Allergies, Lifestyle & Family History

For safe care

Allergies

Lifestyle

Family History

06

Your Situation

Share only what you are comfortable with. All information is kept strictly confidential.

Japan's Maternal Health Act generally requires spousal consent (including common-law). We will accommodate your circumstances.
07

Cost & Service Confirmation

Please review these important details before your visit

Important Information (Costs & Eligibility)

  1. Initial examination fee: approximately 20,000 JPY
  2. Termination procedure fee (if eligible): approximately 110,000 to 130,000 JPY
  3. Eligibility is determined after outpatient examination
  4. We provide medication-induced abortion up to 8 weeks of gestation
  5. Gestational age, comorbidities, medications, supplements, and age (under 18 or over 40 years) may make our service unavailable
  6. Patients must reside within 16 km of our clinic (approximately 30 minutes by car)
  7. Detailed information will be provided after consultation

※ Termination is not covered by Japanese national health insurance (self-pay)
※ If our service is not appropriate for you, we will refer you to another facility

08

Consent & Privacy

Please confirm these final agreements

Privacy Policy

Your personal information is handled in accordance with Japan's Personal Information Protection Act and Medical Care Act.

  • Used for clinical care, medical administration, and billing
  • May be shared with other healthcare or testing facilities when clinically necessary
  • We will not share information with third parties (including family) without your consent
  • Anonymized data may be used for statistics and case studies
  • Questionnaire data is processed only in your browser until you submit

About Your Care

  • Please provide accurate information for safe care
  • Our doctor will clarify any unclear items during your visit
  • If you have urgent symptoms (severe pain, heavy bleeding), please seek medical care promptly
✓

Thank you for completing the questionnaire

Please use the buttons below

📌 For your visit

  • Print the PDF or show it on your smartphone
  • Please bring your insurance card, patient card (if any), and medication card
  • Please prepare the initial examination fee (~20,000 JPY)
  • New patients: please arrive 15 minutes before your appointment