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Skierowanie na badanie profilaktyczne - Grupa LUX MED ... 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the date and location at the top of the form. This information is essential for record-keeping.
- In the 'Kierujemy na badanie' section, select the appropriate type of examination by checking the relevant box: wstępne, okresowe, or kontrolne.
- Fill in the personal details of the individual being referred, including their name, birth date, PESEL number, and address.
- Specify employment details by indicating whether they are currently employed and their job title.
- Detail any harmful factors present in their work environment. Use checkboxes and provide measurements where applicable.
- Complete the section on job responsibilities and any specific conditions that may affect health. Be thorough to ensure accurate assessment.
- 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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