E-Consultation Online

The doctor will conduct a remote consultation and provide recommendations according to medical standards

* Questions marked with a red asterisk must be answered.

*Provide medical conditions and other important information for the doctor.

Previous medical records (optional):

add up to 5 files (pdf, jpg, png)

Patient Data

*First Name

*Last Name

*E-mail

*Phone

Phone

*Street

*House

*City

*Postal Code

*PESEL Number

Select all

I accept the Terms and Conditions of the consultation and the site's Privacy Policy. The information I have provided is accurate. I use the service in my own name and of my own free will.

I declare that I am aware that after filling out the form, the doctor will contact me by phone for a remote consultation.

I declare that I have been informed that entering into an agreement for a telemedicine service does not guarantee the expected benefit. After reviewing the questionnaire and conducting an examination, the doctor will decide whether to issue or deny an e-referral or an e-medical sick note.