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

In what cases is a sick leave certificate not issued:
- When the start of the period of incapacity for work falls no more than 3 days back and 1 day forward from the date of issuance.
- When the break between the issued L4 (regardless of the doctor who issued it) and the requested sick leave is less than 3 days (except for the extension of L4).
- When the total number of days of incapacity for work exceeds 60 days in the last six months.
- When after three attempts to establish telephone contact, the patient does not answer the phone, and the consultation does not take place, the E-Sick Leave will not be issued.
- No possibility of refund! (Applies to the points mentioned above)

* 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.

E-Sick Leave Online

In what cases is a sick leave certificate not issued:

Patient Data