GENERAL QUESTIONNAIRE AND DECLARATION

*Data required by law. You can find the relevant status here: Legal status and explanatory notes. Your data is stored on our servers.

1. Patient Details*

Name and surname

PESEL

Phone number

Address

2. Declaration Regarding Access to Medical Information*

In accordance with §8 point 1) of the Ordinance of the Minister of Health of 9 November 2015 on the types and scope of medical documentation and the manner of its processing (consolidated text: Journal of Laws of 2015, item 2069) I declare that I:

DO NOT authorise anyoneAUTHORISE the following person

to obtain information about the state of my health and/or planned/undergone treatments/procedures.

3. Declaration Regarding Access to Medical Documentation*

In accordance with §8 point 2) of the Ordinance of the Minister of Health of 9 November 2015 on the types and scope of medical documentation and the manner of its processing (consolidated text: Journal of Laws of 2015, item 2069) I declare that I:

DO NOT authorise anyoneAUTHORISE the following person

to access my medical records.

Details of the authorised person (please leave blank if you do not wish to authorise anyone):

Name and surname

Date of birth

Phone number

Address

I agree to the processing of my personal data for the purpose of registering for an online medical consultation, in accordance with the Privacy Policy.