Medical Examination Referral

Get a medical examination referral online in just a few minutes — fast, convenient, and hassle-free.

* Questions marked with a red asterisk must be answered.

*Referral for examination

*Health information

*Are you pregnant?

Yes

*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 website's rules and privacy policy. The information I provided is accurate. I use the service on my own behalf and at my own discretion.

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 a telemedicine service agreement does not guarantee the benefit I expected. After analyzing the questionnaire and conducting an examination, the doctor will decide whether to issue or refuse to issue an electronic prescription, electronic referral, or electronic sick leave, as well as determine the quantity and dosage of the prescribed medications.