1. Personal Information（Required）

Full Name
（as written in passport）Required		 *Please insert a space between names.
Name in Katakana
（for Japanese nationals）Required		 *Please insert a space between names.
Parent or Guardian’s Name
（Persons under the age of 18 and
those unable to sign for themselves）		 *Please insert a space between names.

Relationship：
Date of birthRequired
Under 3 years old（Birth weight:ｇ／Weeks:weeks）

*Vaccination is not possible for infants under 9 months of age.

*In the case of children, family cooperation may be required to ensure the vaccination can be administered safely; if safety cannot be guaranteed, the vaccination may not be possible.

Under 15 years of age: Must be accompanied by a parent or guardian

*Vaccination cannot be administered without a parent or guardian's signature on the medical questionnaire; therefore, attendance with a parent or guardian is mandatory.

Aged 16 or over but under 18:Accompaniment by a parent or guardian is essential.

*Vaccination cannot be administered without a parent or guardian's signature on the medical questionnaire; therefore, attendance with a parent or guardian is mandatory.

Individuals aged 60 or over

*The rate of serious adverse events such as encephalomyelitis and multiple organ failure was 8.3 per 100,000 doses administered, which is higher than the overall reporting rate of 4.7. (Reported in the United States)
GenderRequired
NationalityRequired
（）
Place of Residence & Transportation Method
AddressRequired Postal Code：
Country name：
State：
Prefecture：
City：
Street Address：
Building / Room No.：
Telephone NumberRequired

*Please enter a number where you can be easily reached during the day and on the vaccination date.
Destination CountryRequired
Planned Departure DateRequired
Purpose of TravelRequired
Length of StayRequired
Yellow Fever Vaccine HistoryRequired
Vaccination location：

International Certificate of Vaccination：


Previous adverse reactions：
E-mail AddressRequired

Confirm E-mail Address
Our Hospital ID Number
(Leave blank if none or unknown)

2. Medical Questionnaire （Required）

1Required
Do you have any allergies to eggs, chicken, gelatin, latex, or alcohol disinfectants?
Types of Allergies：
2Required
Have you ever had urticaria (hives), asthma, atopic dermatitis, or allergic rhinitis?
Disease Name：
Have you undergone allergy testing at a medical institution?
Positive Allergens：
3Required
Have you ever experienced adverse reactions (e.g. allergic symptoms) to medications, IV infusions, or vaccinations?
Medication name and specifics：
4Required
Have you received or are you scheduled to receive any vaccinations within the past 4 weeks?
*No other live vaccine may be given within 4 weeks before or after Yellow Fever vaccination.
Other Vaccinations（if applicable）
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5Required
Within the past month, have you had measles, rubella, chickenpox, or mumps?
Have you been in close contact with anyone diagnosed with these diseases?
6Required
Do you currently have any chronic illnesses or take regular medication?
Have you ever had seizures or epilepsy?
Disease names and drug names：

*If you answered “Yes” to any medical questions above, please consult your primary physician regarding vaccination eligibility.
Have you already confirmed this?
7Required
Have you ever been hospitalized or undergone surgery?
Have you received blood transfusions or blood products within the past 3 months?
Disease name / Medication name ：
8
For Female Patients: Are you currently pregnant, possibly pregnant, or breastfeeding?
9Required
Have you been diagnosed with an immunodeficiency or are you taking immunosuppressive medication?

3. Preferred Appointment Dates (Required)

Preferred Appointment DatesRequired


*Please select dates between two weeks from today and within three months.

*If your preferred dates are unavailable, we will contact you to discuss alternatives.
Preferred Contact Time
（multiple selections allowed）Required




*Closed Saturday afternoon and Sundays.
Additional Comments