E-prescription continuation - Form

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In the absence of a PESEL number, it is necessary to provide the passport number, date of birth and country of issue of the passport because issuing an e-prescription without providing the above-mentioned data is impossible.

What diseases are you being treated for? Why are you taking these drugs?

List the drugs you need. Maximum for a 3 months (name, dose, amount)

Since when have you been using these medications?

Have death thoughts been present in the past month? * Question for patients treated for mental disorders.

Yes No

If so, when was the last time?

Have any symptoms of allergies or intolerances occurred after these drugs?

Yes No

Additional information

Name

Surname

PESEL (if absent - providing a passport number is mandatory)

Passport number (entering an incorrect passport number will make it impossible to issue an e-prescription)

Country of issue

Date of birth

Street - current address of your residence (stay)

House / flat number - current address of your residence (stay)

Postal code - current address of your residence (stay)

City - current address of your residence (stay)

Phone number

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.

A prescription will be issued as soon as possible - usually within one hour of registration. In case of doubt, the doctor will call the telephone number provided.

I declare that I am over 18 years old and I am acting on my behalf. All information is truth and actual.

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 the rules, terms of use and the privacy policy of the telemedyk.online portal and I accept all their provisions.

THE DOCTOR WILL MAKE CONTACT AS SOON AS POSSIBLE, USUALLY UP TO 60 MINUTES; IN EXCEPTIONAL SITUATIONS, CONTACT WILL BE MADE BY A MAXIMUM OF 23:00 ON A GIVEN DAY. REGISTRATION AFTER 9PM: THE DOCTOR WILL CONTACT YOU BETWEEN 8AM AND 12PM THE NEXT DAY!

Telemedyk

.online

lek. med. Marcin Łata

Telemedyk

.online

lek. med. Marcin Łata

FILL IN A FORM AND PAY

E-doctor

E-prescription

Telemedyk.online

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Possibility of reimbursing drugs

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