Order Placement for E-prescription

* Questions marked with a red asterisk must be answered.

* Medicine Selection

I want to choose from the list of medications

I will manually enter the name of the medication, as well as the dosages and the number of packages (no more than 2 packages for 2 different medications)

Medical Interview

*Are you pregnant?

Yes

No

Don't know

Do you regularly take any medication?

Yes

No

*Have you had any previous surgeries?

Yes

No

*Have you taken the medication you are ordering now before?

Yes

No

Do you have any allergies to medication?

Yes

No

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 for issuing prescriptions and sick leaves and the Privacy Policy of the website. The information I have provided is accurate. I use the service on my own behalf 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 benefits. After analyzing the questionnaire and a phone consultation, the doctor will decide whether to issue or refuse to issue an electronic prescription, as well as determine the quantity and dosage of prescribed medications.

I declare that I am informed that in the case of ordering a prescription for antidepressants, psychoactive, oncological, and other prohibited drugs without providing supporting documentation from a doctor, the prescription will not be issued, the service will be considered completed, and a refund will not be possible.