Konsultacja telefoniczna z lekarzem specjalistą

Zgłoszenie na konsultację mailową lub telefoniczną z lekarzem specjalistą

Na opisany problem medyczny odpowie lekarz specjalista mailem lub telefonicznie max do 7 dni.
W przypadku wskazań, będzie wystawiona e-recepta. Jest możliwość otrzymania zwolnienia.
Zalecane jest dołączenie zdjęć lub wyników badań.

Uwaga

Na podstawie przesłanych informacji, lekarz będzie się starał jak najlepiej udzielić porady, jednak nie każdy problem zdrowotny może być rozpoznany bez fizykalnego badania.

1. Selecting a physician*

This field is required

2. Your e-mail address*

Please provide your correct email address

3. Your phone number*

This field is required

4. I declare that I am*

Patient/Patient’s parent/Patient’s legal guardian

Person authorised by the patient. If you select this option, you must enclose a scan or picture of your authorisation. You can download a standard form of such authorisation here >>

This field is required

Add an authorisation*

This field is required

5. Information about the patient required for medical records and an e-prescription, if needed

First and family name*

This field is required

PESEL number*

This field is required - digits only

The patient has no PESEL number
Nieprawidłowe dane

Date of birth*

This field is required, if the patient has no PESEL number

Address

This field is required

6. Detailed description of the patient’s medical problem.

Answering the following questions may help describe the problem

What are the symptoms?
Is there pain, itching, burning?
When and how did the symptoms start?
Is it the first time that such symptoms have developed?
Were these symptoms treated before and how?
Did anyone in the family have similar conditions?
Does the patient have any other medical conditions, especially: liver or kidney diseases, hypertension, diabetes, heart attack, stroke, coronary disease, cancer, psoriasis, albinism, AD, confirmed allergy, other
What regular drugs does the patient take?
Does the patient smoke or drink alcohol?
Is the patient on a diet?
Patient’s weight and height

Incorrect data

7. It is recommended to enclose pictures, test results or other information

jpg/png/pdf file
Max. size 5MB
You can add multiple files

add

Incorrect data

8. Fill in the fields below, if you want to receive an invoice

I do not need an invoiceinvoice issued to a natural personinvoice issued to a company Nieprawidłowe dane

First and family name*

Required field

Company name*

This field is required

NIP (tax) number*

This field is required

street*

This field is required

I confirm that all the information provided by me is true. * The consent is required

I confirm that I have read and accept the provisions of the Contract and the Terms and Conditions of the Provision of Consultations by Electronic Means by: Centrum Dermatologiczno - Alergologiczne „Derm-Al” Sp. z o.o. * The consent is required

I confirm that I have read and accept the GDPR privacy policy of Centrum Dermatologiczno - Alergologiczne „Derm-Al” Sp. z o.o. * The consent is required

Zgłoszenie na konsultację mailową lub telefoniczną z lekarzem specjalistą

Uwaga

contact

Contact

Dermatology and Allergy Centre Derm-Al Sp. z o.o

Derm-Al Beauty

Team

Treatments

INDICATIONS

We accept medipacks

We accept credit cards

Installment payments

Zgłoszenie na konsultację mailową lub telefoniczną z lekarzem specjalistą

Uwaga

contact

Contact

Dermatology and Allergy Centre Derm-Al Sp. z o.o Derm-Al Beauty

Team

Treatments

INDICATIONS

Dermatology and Allergy Centre Derm-Al Sp. z o.o

Derm-Al Beauty