GENERAL QUESTIONNAIRE AND DECLARATION

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1. PATIENT DETAILS*
2. DECLARATION REGARDING ACCESS TO MEDICAL INFORMATION*
In accordance with §8 point 1) of the Ordinance of the Minister of Health of 9 November 2015 on the types and scope of medical documentation and the manner of its processing (consolidated text: Journal of Laws of 2015, item 2069) I declare that I:
DO NOT authorise anyoneAUTHORISE the following person
to obtain information about the state of my health and/or planned/undergone treatments/procedures.

3. DECLARATION REGARDING ACCESS TO MEDICAL DOCUMENTATION*
In accordance with §8 point 2) of the Ordinance of the Minister of Health of 9 November 2015 on the types and scope of medical documentation and the manner of its processing (consolidated text: Journal of Laws of 2015, item 2069) I declare that I:
DO NOT authorise anyoneAUTHORISE the following person
to access my medical records.

Details of the authorised person (please leave blank if you do not wish to authorise anyone):

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Przedstaw się *
Wiadomość *