Questionnaire

Dear clients,
As part of your forthcoming treatment we have prepared the following questionnaire, which serves to facilitate the communication between you and our physician. Please complete the questionnaire by filling all the required data. Do not hurry, take your time. The information in the questionnaire is of high importance for us and it will help the physician in designing the best treatment option for you.

This is secured via encryption and an SSL certificate issued by a certificate authority for the company Gynekologie MEDA Ltd., which provides communication between you and the data server. The data is treated sensitively, we protect it from misuse and never provided it to a third party.

Thank you for your assistance, we are wishing you a successful treatment. Please fill in all the following data.

Contact Form

I. Personal data

II. Medical questionnaire

III. Additional information

Your data are handled in accordance with the Act No. 101/2000 Coll. on Personal Data Protection. All the personal data (such as name, address, phone number, e-mail, birth number etc.), which you disclose to us during your e-communication, are considered as discrete by our company and they are protected against misuse under the law. We bind to use your personal data only for our needs and not to provide them in any form to another person (except for those persons directly involved in your treatment and only in a the required amount).