Downloadable Forms

Regulations

• Principles of providing health services
• Regulations for the use of E-Reservation of the LUXMED Medical Center sp. z o. o.
• Mobile application terms and conditions
• Complaints regulations
• Rehabilitation Department Regulations
• Terms and conditions for granting discounts on services
• Guarantee for dental treatment
• Gift Card (aesthetic medicine / cosmetology)
• GDPR

Patient declarations and consents

•  Patient's declaration - authorized persons
•  Declaration of a parent or legal guardian
•  Confirmation of the accuracy of personal data
•  Consent to the processing of personal data

Surveys

•  Patient questionnaire - urine sediment cytology
•  PZU Survey – Medical Care
•  PEMPHIGUS antibody test questionnaire

Referrals

•  Referral for histopathological examination/biopsy
  
•  Referral for Salmonella and Shigella testing
•  Referral for preventive examinations
•  Referral for a psychological assessment for a course (forklift operator, backhoe loader operator, crane operator, firefighter, municipal guard)
•  Referral for psychological testing (for drivers)
•  Referral for cytological testing
•  Referral and consent for genetic testing (HCV) LUXMED
•  Referral and consent for genetic testing (HPV, Chlamydia trachomatis) LUXMED
•  Deklaracja świadomej zgody na badanie genetyczne
•  Referral for genetic testing (Borrelia burgdorferii, Cytomegalovirus, HBV)
•  Referrals for the WB anti-HIV confirmation test.
•  Referral for prenatal tests from the National Health Fund
•  Referral for molecular testing
•  Referral for molecular testing – Euroimmun
•  SANCO test research form
•  FABER test form
•  Blood group identification card form
•  Order for HPA-1 Antigen Phenotype Test

Applications and complaints

•  Online complaint submission form
•  Complaint form
  

Other prints

•  Food diary
•  Patient's statement
•  Guardian's Declaration
•  Consent to vaccination
• Internal reporting procedure

Detailed information about HIV testing: