General Consent to Consultation and Treatment at Kyushu
University HospitalThis form is to explain about general rule for patients to receive consultation andtreatment at Kyushu University Hospital. If you have any questions about the contents
below, please feel free to ask anytime.
In case you do NOT agree after the explanation, you can still reject to receive
consultation and treatment at Kyushu University Hospital.
１．Treatment and Examinations(1) Hospitalization/frequent visit may be considered depending on the results of yourexamination/procedure. Depending on the circumstances, you may need to transfer toa different hospital.

(2) Your doctor or hospital staff will explain about significant and risk of thetreatment to you each time. Please receive the treatment only in case you agree withthe explanation.
(3)

In case you cannot be admitted, visit the hospital or stop the treatment for yourown reasons, various risk such as treatment is not performed appropriately mayoccur.

２．Financial Responsibility(1) International patients who are not eligible to have a Japanese insurance will becharged 200 % for medical fee. This rule applies to Japanese patients residing
overseas who are not eligible to have a Japanese insurance.
(2) Medical fee shall be paid without any delay as soon as your consultation is finished.
(3) Even in the event that you stop the treatment for your own reasons or diagnosis ortreatment is not as you expected, you are responsible for payment of all charges forservices provided by the Hospital.
(4) Treatment period may be prolonged depending on unexpected complications orexacerbations. Patients are responsible for payment of all the expenses such as
medical fee, accommodation fee and visa extension fee in that case.
３．Translation(1) We do not translate your medical record or data from previous hospital to Japanesein Kyushu University Hospital. Please translate all your documents to Japanese(English is also acceptable) in advance and bring them to the hospital.
(2) If all your documents (data) required for consultation are not translated accurately,
it may affect diagnostic accuracy in the hospital. Please understand that it may takemore time and cost for additional examination in that case.

1(3) Patients who have a difficulty in communicating in Japanese is required to bring atranslator in general rule at Kyushu University Hospital.
(4) The hospital is free from medical responsibilities under any circumstances such as
misunderstanding or miscommunication through translators.
４．Referral System(1) Referral letter from your primary doctor is necessary in general rule at Kyushu
University Hospital. We may need to refer you to your primary doctor you’re yourcondition is settled after treatment in this hospital.

５．Personal Information(1) Your personal information provided for the treatment shall be kept confidential
strictly as indicated in ”Basic Policy of Personal Information in Kyushu University
Hospital”; however, the Hospital may disclose your medical information forcooperation with other medical facilities and nursing homes.
６．Others(1) Please follow the instruction from hospital staff to keep social conventions andHospital rules. Please also refrain from disturbing other patients or being anuisance.

(2) The official language of consent forms used in Kyushu University Hospital isJapanese. In the event that a translation hereof is made in other languages, any suchtranslation shall have no effect on the interpretation of the original.
(3) The consent forms used in Kyushu University Hospital shall be governed by andconstrued in accordance with the law of Japan. Jurisdiction and venue for any claim
or dispute arising from the service provided by Kyushu University Hospital shall be
subject to the exclusive jurisdiction of the Fukuoka District Court in the firstinstance.

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