Skierowanie na badanie profilaktyczne - Grupa LUX MED ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date and location at the top of the form. This information is essential for record-keeping.
3. In the 'Kierujemy na badanie' section, select the appropriate type of examination by checking the relevant box: wstępne, okresowe, or kontrolne.
4. Fill in the personal details of the individual being referred, including their name, birth date, PESEL number, and address.
5. Specify employment details by indicating whether they are currently employed and their job title.
6. Detail any harmful factors present in their work environment. Use checkboxes and provide measurements where applicable.
7. Complete the section on job responsibilities and any specific conditions that may affect health. Be thorough to ensure accurate assessment.
8. Finally, ensure that a signature and stamp from the referring person are included at the bottom of the form before submission.

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