แบบฟอร์ม · ภาษาไทย
แบบฟอร์มแจ้งความ
Disclosure and notification form for informing patients of diagnoses or procedures.
- Form type
- kokuchi
- Language
- Thai (ภาษาไทย)
- Archive source
- AMDA-IMIC Japan forms library, 2013–2024
About This Form
This page documents the แบบฟอร์มแจ้งความ as provided in Thai through AMDA-IMIC's multilingual forms library. The form is used for: disclosure and notification form for informing patients of diagnoses or procedures..
Informed consent and diagnostic disclosure in Japan follow specific legal and procedural standards under the Medical Care Act. The notification form documents that a patient has been informed of a diagnosis, prognosis, or planned procedure in a language they understand. For non-Japanese-speaking patients, this documentation is especially important as it confirms that interpretation was provided and that the patient's comprehension was verified. AMDA-IMIC produced this form to support clinics serving foreign patients who required disclosure in a language other than Japanese.
For the original administrative forms in active use, contact the relevant Japanese institution directly — a hospital, employer, local health center, or labor bureau — depending on which form is needed. This reference documents the structure and purpose of the forms as they were used during the 2013–2024 period when AMDA-IMIC was operating.
Form Sections and Fields
The following sections and fields appear in the Thai version of this form. Field labels are rendered here in English for reference; the original form presents them in Thai (ภาษาไทย).
- Patient full name and date of birth
- Date of notification
- Attending physician name and specialty
- Diagnosis or condition being disclosed (name and brief description)
- Prognosis summary (where applicable)
- Planned procedure or treatment (name, date, expected duration)
- Risks and alternatives explained (checkbox confirmation)
- Language in which notification was delivered
- Interpreter name and qualification (if used)
- Patient signature confirming receipt of notification
- Physician or institution seal and date
How to Obtain This Form
The forms documented on this site were originally distributed by AMDA-IMIC through its consultation service and language-specific subdomains. Since the center closed in 2024, the forms are no longer distributed through that channel. Equivalent forms for current use are available from the relevant Japanese institution: municipal health centers issue administrative forms, hospitals provide their own registration and appointment materials, and the Labor Standards Inspection Office supplies labor insurance documentation.