ORDER CONSULT WITH DOCTOR REGARDING SICK NOTE UP TO 1 WEEK 119 ZŁ

* skip if you have already paid

SICK NOTE CONSULTATION PAGE          

Provide information regarding reason for sick note, especially symptoms you are currently experiencing.

If you had not yet paid for the consultation at the bottom of the page you can find the ORDER consultation. Once both the payment and the form is received the order can be approp

Name
Last name
e-mail:
Telephone number
NR  PESEL  (polish number if applicable)
Street and number
City
Postal code
Job performed
NIP number (or numbers) of employer(s)
Sick note dates requested start at
Sick note dates requested end at
expectations
Please mark any symptoms you are having or had during this illness
Chest pain
Short of breath
Loss of consciousness
runny nose
dry cough
productive cough
sneezing
general malaise
diarrhoea
vomitting
pain or burning during urination
chills
back pain
symptoms of sciatica
other - specify in field " State any other conditions or symptoms relevant"
Did you feel an increased temperature
What was the highest temperature measurement
medication you normally are on
Mark any conditions a doctor diagnosed you with
Migraine ( by neurologist )
other headache
Arrythmia
Asthma
Heart failure
Kidney failure
Liver failure
Heart defects
Cancer or malignancy
Immune system defects or immunosuppresion
Aortic aneurysm
other arterial aneurysm
Deep venous thrombosis
Varicose veins
State any other conditions or symptoms relevant
( women ) Are you pregnant ?
( women ) Are you breast feeding ?
( women ) Are you planning to be pregnant in the following weeks ?
Did you have difficulties in getting a consult at your normal health care provider for example POZ / NFZ ?
Acceptance of processing of personal information as in the information processing document
I hereby accept processing of my personal information
Do you accept the terms of the service?
I hereby understand and accept the terms of the service. I also understand the the doctor may deny the sick note in certain cases, such as repeated sick note requests without physical confirmation of symptoms. In case of first denial there is no charge, however in next denial, the money is returned minus administration fee of 29 zł.
Do you confirm the anwsers to all questions?
yes
Additional information.
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SEND FORM
FORM has been sent - thank you !
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