SUBMIT ORDER FOR

CONSULT FOR

PRESCRIPTION

79 zł

 Health questionaire

You can request contact regarding a online prescription consultation here.

If you had not made a payment once you send the form, you can click the ORDER button.

State all the necessary details below and any other information you believe is important such as that regarding the medication type, reason for treatment, other medications you are on and more.

Name
Last name
e-mail:
Telephone number
NR  PESEL  (polish number if applicable)
Street and number
City
Postal code
expectations
Medications requested number 1
Reason for treatment number 1
Medications requested number 2
Reason for treatment number 2
Medications requested number 3
Reason for treatment number 3
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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FORM has been sent - thank you !
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