E-Sick Leave Online

After filling out the form, the doctor will conduct a consultation and decide on issuing an e-sick leave based on medical indications

* Questions marked with a red asterisk must be answered.

*Employment

Select employment

Employee
Uniformed services worker
Student / Pupil
Employee in a foreign company

*Employer's NIP

*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 telemedicine services does not guarantee the expected benefits. After analyzing the questionnaire and conducting a phone consultation, the doctor will decide whether to issue or refuse to issue an electronic prescription, referral, or sick leave, as well as determine the quantity and dosage of prescribed medications.

I declare that I have been informed that refusal to answer the doctor's call will result in refusal to issue an electronic prescription with no refund.