Documents for teleconsultation

Please submit your documentation no later than one hour before your visit.

Information regarding the processing of personal data is included in the Privacy Policy

Name:
Last name:
PESEL:
No PESEL number:
Date of birth:
Name of service/clinic:
Type of service:
Doctor:
Date of visit:
E-mail:
Attachment:
Attachment:
Attachment:
Attachment:

	I have read the information on the processing of personal data described in the Privacy Policy.
	I have become familiar with the rules for providing health services at CM Luxmed.