Please fill in all required fields. After submitting, please remain seated — a staff member will call you when ready.

Basic Information

Full NameRequired

Please enter your name in English (letters only), exactly as it appears on your passport.

Please enter your name in English letters, as shown on your passport.

GenderRequired

Male Female

Please select your gender.

Date of BirthRequired

Enter 8 digits in the order Year / Month / Day (slashes are added automatically).

Please enter a valid date (YYYY/MM/DD).

Age (calculated automatically)

Medication can only be prescribed to those aged 18 and over.

Passport NumberRequired

Half-width letters and numbers only.

Please enter your passport number (letters and numbers only).

WhatsApp number (if you have one)

Optional.

I need customs documentation for carrying the medication abroad (free of charge).

Body Information

HeightRequired

Please enter your height.

WeightRequired

Please enter your weight.

BMI (calculated automatically)

Medication cannot be prescribed to those with a BMI of 18.5 or below.

Requests / Medical History / Medications

Please enter the medication, dose, and quantity you would like.Required

Please enter the medication you would like.

Past medical history (illnesses, surgeries, etc.). Write “None” if not applicable.Required

Please fill in your past medical history.

Please list all medications you are currently taking.Required

List all medication names. Write “None” if not taking any.

Please fill in your current medications.

Contraindications / Confirmation

Have you ever had pancreatitis or a bowel obstruction (ileus)?Required

Yes No

Medication cannot be prescribed to those with a history of pancreatitis or bowel obstruction.

Please select an option.

Do you have any allergies to medication or food? Write “None” if not applicable.Required

Please fill in any allergies (or “None”).

Does anyone in your family have medullary thyroid cancer or Multiple Endocrine Neoplasia (MEN) type 2?Required

Yes No

Medication cannot be prescribed in this case.

Please select an option.

Are you pregnant or breastfeeding, planning pregnancy within 3 months, or within 3 months after childbirth?Required

Yes No

Medication cannot be prescribed in this case.

Please select an option.

For patients who would like a detailed consultation with the doctor A medical diet consultation basically consists of reviewing the questionnaire and confirming your identity.
If you would like any of the consultations below, an additional consultation fee of ¥5,500 applies (consultation in English only).

How to use the injection
Which medication is right for me
Adjusting the dose or timing of administration
How to manage side effects

I would like a detailed consultation with the doctor (consultation fee ¥5,500, in English).If you do not purchase any medication, an additional ¥11,000 applies.