Consultation with a psychologist - Form

The reason for the visit

Have "s" thoughts been present in the past month?

Yes No

If so, when was the last time?

Additional information

Name

Surname

Email

Phone

PESEL (if absent - providing a passport number is mandatory

Add medical documentation (discharge from the hospital, medical certificates, confirmations of medications used, available at https://pacjent.gov.pl/internetowe-konto-pacjenta) - only if you have such documentation

I certify that I am 18 years of age and that I am acting on my behalf. All data is true and true to my health.

I declare that I consent to the processing of my personal data for the purpose of medical consultation. I agree to receive phone calls / SMS / e-mail.

I have read all the rules, regulations of the telemedyk.online portal and the privacy policy and I accept all their provisions.