Patient Registration

First Name*

Last Name*

Date of birth (dd/mm/yyyy)*

To make an appointment, please indicate the date of birth (DD / MM / YYYY)

Sex*

PESEL

Photo ID

Citizenship*

Type of document2*

EU citizenship*

non-EU citizenship*

Document number*

Date of issue (dd/mm/yyyy)*

Date of expiry (dd/mm/yyyy)*

Authority*

Code of Issuing*

Address*

Street Address City ZIP / Postal Code Country

Phone with prefix code**

Email*

Enter Email Confirm Email

Partner's name

The Clinic in which you are treated or you want to be treated*

Preferred consultation date (monday-friday)*

(dd/mm/yyyy)

Initial Visit*

Female preliminary tests to be performed in*

Male preliminary tests to be performed in*

Genetic tests for female and male to be performed in*

Untitled*

I declare that I have familiarised myself with the Regulations and Information from the Administrator.

Medipoint

I hereby certify under penalty of perjury, that all the information contained in this document is true and correct. I give the consent to the personal and medical data being sent to my account on the Patient Portal in Medipoint.pl.

I give my consent to the processing of my personal data in an automated manner, including the form of profiling, for marketing purposes, consisting in combining data received from you with the information about your characteristics, behaviour, preferences in order to match commercial information to the known or anticipated needs or expectations (profiling).

Name

This field is for validation purposes and should be left unchanged.

Get in touch / Book an appointment