YUI CLINIC CONSENT FORM & EXPLANATION

Gonococcal Examinations and/or Eye drops Administration to Babies

Chlamydia infection, a sexually transmitted disease, is a relatively infectious

disease, so everyone is examined during pregnancy medical examinations. However,
Neisseria gonorrhoeae is not included in pregnancy medical examinations because of
its low infection rate compared with Chlamydia.

Neisseria gonorrhoeae is a causative bacterium of gonorrhea. In women,

inflammation occurs in the uterine cervix (a narrow part leading from the vagina to the
uterus), and cervicitis and stomatitis may cause the bacterium to spread within the
pelvis, resulting in peritonitis. In addition, it is known that there is a possibility of
causing mother-to-child infection at birth, and both eyes of a newborn baby are often
attacked, and sometimes it can result to blindness if left unattended.

Generally, it is recommended that newborn babies are given prophylactic doses

of eye drops within 2 hours from birth in order to prevent an eye infection caused by
Chlamydia and Neisseria gonorrhoeae. If it can be confirmed that there are no
infectious diseases of Neisseria gonorrhoeae and Chlamydia, it is considered possible
not to administer the eye drops.

At this clinic, we are checking whether or not to use eye drops for babies. In
addition, because the infection rate of Neisseria gonorrhoeae is low, it is possible not to
ask for gonococcal examination and not to apply eye drops to newborns. However, if
symptoms suspected of eye infection in postnatal newborn infants, eye drops are
administered regardless of whether they are positive or negative for infectious disease
test results. In that case, it is not a single prophylactic administration, but therapeutic
eye drops from 4 to 6 times a day are required.

Eye drops are at 150 yen at their own expense when prophylaxis is
administered.

o I will take a gonococcal exam. (Cost 2200 yen)

o I hope for eye drops. I do not want eye drops.
o I do not take a gonococcal exam. I would like an eye drop to a newborn baby.
o I do not take a gonococcal exam. I do not want eye drops for newborn babies.

Date

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