「外来の付き添い」、「入院中の面会」、「分娩立ち合い」について

Necessary measures to protect outpatients, hospitalized patients, pregnant
women and babies against infectious diseases and accidents.
We ask for your active understanding and cooperation.
<About " attendant of outpatient", "visit to hospitalized patient", and "attendant atdelivery">On May 8, 2023, the new coronavirus infectious disease is classified as the 5th category in theJapanese Infectious Disease Law, and the rules regarding "attendant of outpatient”, "visit tohospitalized patient", and "attendant at delivery" at our clinic are changed. The rules may bechanged without notice depending on the spread of various infectious diseases including the newcoronavirus infection in future. In order to prevent infectious diseases and security measures, wehave established some rules as follows regarding "attendant of outpatient”, "visit to hospitalized
patient", and "attendant at delivery". We kindly ask all of our family members and others toabide by the rules. If we discover any violations, we will take strict measures such as prohibiting
future visits to the clinic.

[Common rules for visitation during attendant of outpatient , visit to hospitalized patient
hospitalization, and attendant at delivery]
・Wear a mask in the clinic.
・Only family menbers including common-law relationship is possible, except when requested byour clinic.
・No symptoms such as fever or cough (excluding those not due to infectious diseases such asallergic rhinitis).
・In the past week, there is no contact with patients with COVID-19 or seasonal / new influenza,
or with infectious diseases stipulated in the Japanese Infectious Diseases Law.
・Follow the instructions of our clinic staff.

[Regarding accompanying family members]
・No more than one accompanying adult.
・Please refrain from coming to the doctor with children as much as possible. If this is not possible,
please be careful not to cause discomfort to other patients.
・An accompanying adult shall not wait in the outpatient waiting room. Please think of yourchildren in the same way.
・Patients with only children should wait in the waiting room with their children.
・An accompanying adult has to leave the clinic as soon as the examination is over.

「外来の付き添い」、「入院中の面会」、「分娩立ち合い」について[Regarding visitation during hospitalization]
・Please fill in the visitation reception book and submit the health declaration form.
・Except for special timing such as before and after childbirth or when requested by our clinic,
visits are limited to visiting hours.
・Visitors are limited to one family adult only and once a day. Please confirm the visiting hours
when you are admitted to the hospital.
・Your children cannnot visit the clinic. ・・Please refrain from staying in shared spaces such as corridors and halls.
・Newborns will be seen through the glass in front of the neonatal room.
・Visitors should refrain from eating and drinking in the clinic.

[About attending childbirth]・There is only one person who attends the delivery, and the spouse (including the partner) or an
adult female member of the family (mother, sister, etc.).
- Minimize boing into or out of the clinic.
・Your children are not able to attend the childbirth and to wait in the hospital room.
・At the start of the delivery, you will be required to submit a declaration and written pledge as aattendance of childbirth.
・In some cases, depending on the contents of the birth witness report and pledge, we may not beable to approve the birth attendance.

Director of Iris Women's Clinic

「外来の付き添い」、「入院中の面会」、「分娩立ち合い」についてChildbirth attendant declaration/pledge
If you plan to attend the childbirth on the day of hospitalization, please fill in this form yourself.
Date of admission(d/m/y):Patient's name:
Persons planning to attend childbirth:Age:years old

Address:
Information on the person who is scheduled to attend the delivery
Body temperature:.

Degrees (hour measurement)□ No subjective symptoms at all□ Fever □ Sore throat □ Cough □ Phlegm □ Shortness of breath □ Feeling tired□ Smell/taste is difficult to distinguish □ Diarrhea □ Other (）

Please answer about the situation of the person who is scheduled to attend the childbirth in thelast week.
There was a contact with a patient with a disease listed in Japanese Infection Law such as the
new coronavirus infection.

□ Yes

□ No

Many people around them have symptoms suggestive of infectious diseases, such as coughing
and nasal discharge.

□Yes

□No

Had a fever of 37.5 degrees or higher.

□ Yes

□ No

He had symptoms such as sore throat, fatigue, and loss of smell and taste. □ Yes□ No

I had a meal with people other than my family, such as friends, colleagues at work, and business
partners, without any infection control measures. □ Yes□ No

I went to karaoke, snack bars, live houses, clubs, and other places where there were many people,
crowded/closed spaces, close contact, or loud singing.

□ Yes

□ No

-------------------------------------------------- ------------------□ I promise to fully cooperate with hospitalization and childbirth according to the instructions of
the staff.
Name of person scheduled to attend (signature)(d/m/y):「外来の付き添い」、「入院中の面会」、「分娩立ち合い」についてVisitation Application/Declaration Form
Date of meeting (d/m/y):Visiting patient's name:
Body temperature:

Relationship.

℃□ No subjective symptoms at all□ Fever □ Sore throat □ Cough □ Phlegm □ Shortness of breath □ Feeling tired□Smell/taste is difficult to distinguish □ Diarrhea□ Other (）