{"id":450,"date":"2024-07-23T00:19:18","date_gmt":"2024-07-22T22:19:18","guid":{"rendered":"https:\/\/polskilek.proadax-dev.pl\/?page_id=450"},"modified":"2024-07-23T00:19:18","modified_gmt":"2024-07-22T22:19:18","slug":"jestem-lekarzem-lub-inna-osoba-wykonujaca-zawod-medyczny","status":"publish","type":"page","link":"https:\/\/polskilek.pl\/es\/formularz-zglaszania-dzialania-niepozadanego\/jestem-lekarzem-lub-inna-osoba-wykonujaca-zawod-medyczny\/","title":{"rendered":"Jestem lekarzem lub inn\u0105 osob\u0105 wykonuj\u0105c\u0105 zaw\u00f3d medyczny"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6-o1\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"6\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/450#wpcf7-f6-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-scroll cf7mls-auto-return-first-step cf7mls-no-moving-animation\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"6\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_ip\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"fieldset-cf7mls-wrapper\" data-transition-effects><fieldset class=\"fieldset-cf7mls cf7mls_current_fs\"><h4>Krok 1 - Informacje o pacjencie\n<\/h4>\n<div class='alert'>\n\t<p><strong>Wa\u017cna informacja!<\/strong><br \/>\nKroki lub pola obowi\u0105zkowe zosta\u0142y opisane, lecz wype\u0142nienie pozosta\u0142ych p\u00f3l formularza u\u0142atwi ocen\u0119 zwi\u0105zku przyczynowo - skutkowego mi\u0119dzy produktem lecznicznym a dzia\u0142aniem niepo\u017c\u0105danym. Prosimy o mo\u017cliwie kompletne wype\u0142nienie formularza.\n\t<\/p>\n<\/div>\n<p><label> Inicja\u0142y pacjenta *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n<\/p>\n<p><label>P\u0142e\u0107 *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"your-sex\" value=\"Kobieta\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Kobieta<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"your-sex\" value=\"m\u0119\u017cczyzna\" \/><span class=\"wpcf7-list-item-label\">m\u0119\u017cczyzna<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<p><label>Data urodzenia<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birth-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"birth-date\" \/><\/span><\/label>\n<\/p>\n<p><label>Wiek *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"wiek\" \/><\/span><\/label>\n<\/p>\n<p><label>Masa cia\u0142a *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"weight\" \/><\/span><\/label>\n<\/p>\n<p><label>Wzrost *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"height\" \/><\/span><\/label><br \/>\n<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-1\" style=\" \">Nast\u0119pny krok<img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h4>Krok 2 - informacje o dzia\u0142aniu niepo\u017c\u0105danym\n<\/h4>\n<hr \/>\n<p><label class='full-width'> Nazwa leku podejrzanego o wyst\u0105pienie dzia\u0142ania niepo\u017c\u0105danego \/ nazwa substancji czynnej *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-medicine\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-medicine\" \/><\/span> <\/label>\n<\/p>\n<p><label> Numer serii *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-series\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-series\" \/><\/span> <\/label>\n<\/p>\n<p><label>Termin wa\u017cno\u015bci<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicine-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medicine-date\" \/><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label class='full-width'> Dawkowanie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-portion\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-portion\" \/><\/span> <\/label>\n<\/p>\n<p><label>Data rozpocz\u0119cia podawania<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-portion-start\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-portion-start\" \/><\/span><\/label>\n<\/p>\n<p><label>Data zako\u0144czenia podawania<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-portion-end\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-portion-end\" \/><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label class='full-width'> Przyczyna u\u017cycia<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-reason\" \/><\/span> <\/label>\n<\/p>\n<p><label>Data wyst\u0105pienia objaw\u00f3w *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-illness\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required datepicker\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-illness\" \/><\/span><\/label>\n<\/p>\n<p><label>Opis objaw\u00f3w *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opis\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opis\"><\/textarea><\/span><\/label>\n<\/p>\n<h4>Klasyfikacja\n<\/h4>\n<hr \/>\n<p><label>Czy dzia\u0142anie niepo\u017c\u0105dane by\u0142o ci\u0119\u017ckie?<br \/>\n<small>Do ci\u0119\u017ckich objaw\u00f3w zaliczamy m.in zgon lub zagro\u017cenie \u017cycia, hospitaliacj\u0119, trwa\u0142e lub znacz\u0105ce inwalidztwo lub inne istotne medycznie powik\u0142ania<br \/>\n<\/small><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-637\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-637\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-637\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label>Zaznacz wszystkie punkty odpowiadaj\u0105ce reakcji<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-572\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"zgon\" \/><span class=\"wpcf7-list-item-label\">zgon<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"zagro\u017cenie \u017cycia\" \/><span class=\"wpcf7-list-item-label\">zagro\u017cenie \u017cycia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"hospitalizacja lub jej przed\u0142u\u017cenie\" \/><span class=\"wpcf7-list-item-label\">hospitalizacja lub jej przed\u0142u\u017cenie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"trwa\u0142e lub znacz\u0105ce inwalidztwo lub upo\u015bledzenie sprawno\u015bci\" \/><span class=\"wpcf7-list-item-label\">trwa\u0142e lub znacz\u0105ce inwalidztwo lub upo\u015bledzenie sprawno\u015bci<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"choroba, wada wrodzona lub uszkodzenie p\u0142odu\" \/><span class=\"wpcf7-list-item-label\">choroba, wada wrodzona lub uszkodzenie p\u0142odu<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-572[]\" value=\"inne, istotne medycznie\" \/><span class=\"wpcf7-list-item-label\">inne, istotne medycznie<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label>Wynik<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-575\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-575[]\" value=\"powr\u00f3t do zdrowia bez trwa\u0142ych nast\u0119pstw\" \/><span class=\"wpcf7-list-item-label\">powr\u00f3t do zdrowia bez trwa\u0142ych nast\u0119pstw<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-575[]\" value=\"jest w trakcie leczenia objaw\u00f3w\" \/><span class=\"wpcf7-list-item-label\">jest w trakcie leczenia objaw\u00f3w<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-575[]\" value=\"brak powrotu do zdrowia\" \/><span class=\"wpcf7-list-item-label\">brak powrotu do zdrowia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-575[]\" value=\"niewiadomy\" \/><span class=\"wpcf7-list-item-label\">niewiadomy<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-575[]\" value=\"powr\u00f3t do zdrowia z trwa\u0142ymi nast\u0119pstwami (jakimi?)\" \/><span class=\"wpcf7-list-item-label\">powr\u00f3t do zdrowia z trwa\u0142ymi nast\u0119pstwami (jakimi?)<\/span><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p>[group group-531]<label><span class=\"wpcf7-form-control-wrap\" data-name=\"nastepstwa\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"nastepstwa\"><\/textarea><\/span><\/label>[\/group]\n<\/p>\n<hr \/>\n<p><label>(Dotyczy kobiet) Czy w trakcie przyjmowania pacjentka by\u0142a w ci\u0105\u017cy?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-kobiet\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-kobiet\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-kobiet\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p>[group group-927]<br \/>\n<label> W kt\u00f3rym tygodniu?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-tydzien\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-tydzien\" \/><\/span> <\/label>[\/group]<div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-2\" style=\" \">Poprzedni krok<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-2\" style=\" \">Nast\u0119pny krok<img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h4>Krok 3 - informacje o innych stosowanych lekach\n<\/h4>\n<hr \/>\n<p><label> Nazwa leku<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-medicine-new\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-medicine-new\" \/><\/span> <\/label>\n<\/p>\n<hr \/>\n<p><label> Dawkowanie (np. 20 mg 2x dziennie)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dawkowanie-leku\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dawkowanie-leku\" \/><\/span> <\/label>\n<\/p>\n<hr \/>\n<p><label> Spos\u00f3b podania (np. doustnie)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sposob-podania\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sposob-podania\" \/><\/span> <\/label>\n<\/p>\n<p><label>Data rozpocz\u0119cia podawania<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-rozpoczecia-podawania\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"data-rozpoczecia-podawania\" \/><\/span><\/label>\n<\/p>\n<p><label>Data zako\u0144czenia podawania<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-zakonczenia-podawania\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"data-zakonczenia-podawania\" \/><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label> Przyczyna podawania leku (np. nadci\u015bnienie)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"przyczyna-podawania\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"przyczyna-podawania\" \/><\/span> <\/label><div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-3\" style=\" \">Poprzedni krok<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-3\" style=\" \">Nast\u0119pny krok<img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h4>Krok 4 - informacje dodatkowe\n<\/h4>\n<hr \/>\n<p><label>Czy lek by\u0142 stosowany po raz pierwszy?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-821\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-821\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-821\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label>Czy dzia\u0142ania niepo\u017c\u0105dane by\u0142y notowane wcze\u015bniej?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-822\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-822\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-822\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label>Czy pacjent cierpi na alergie lub inne choroby?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-823\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-823\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-823\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p>[group group-426]<br \/>\n<label> Jakie?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"krok-4-jakie\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"krok-4-jakie\" \/><\/span> <\/label>[\/group]\n<\/p>\n<hr \/>\n<p><label>Czy pacjent jest w posiadaniu wynik\u00f3w bada\u0144 dodatkowych po wyst\u0105pieniu dzia\u0142ania niepo\u017c\u0105danego?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-824\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Tak<\/span><input type=\"radio\" name=\"radio-824\" value=\"Tak\" checked=\"checked\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Nie<\/span><input type=\"radio\" name=\"radio-824\" value=\"Nie\" \/><\/label><\/span><\/span><\/span><\/label>\n<\/p>\n<hr \/>\n<p><label> Inne dane mog\u0105ce mie\u0107 zwi\u0105zek z dzia\u0142aniem niepo\u017c\u0105danym<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"krok-4-jakie2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"krok-4-jakie2\" \/><\/span> <\/label><div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-4\" style=\" \">Poprzedni krok<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-4\" style=\" \">Nast\u0119pny krok<img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h4>Krok 5 - Dane osoby zg\u0142aszaj\u0105cej\n<\/h4>\n<hr \/>\n<p><label> Imi\u0119 i nazwisko *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"imie-nazwisko\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"imie-nazwisko\" \/><\/span> <\/label>\n<\/p>\n<hr \/>\n<p><label> Specjalizacja *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"specjalizacja\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"specjalizacja\" \/><\/span> <\/label>\n<\/p>\n<hr \/>\n<p><label> Telefon *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"+48\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span> <\/label>\n<\/p>\n<h4>Adres\n<\/h4>\n<p><label> Ulica i numer budynku<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ulica\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ulica\" \/><\/span> <\/label>\n<\/p>\n<p><label> Numer lokalu<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"lokal\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lokal\" \/><\/span> <\/label>\n<\/p>\n<p><label> Kod pocztowy<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kod\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kod\" \/><\/span> <\/label>\n<\/p>\n<p><label> Miejscowo\u015b\u0107<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"miejscowosc\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"miejscowosc\" \/><\/span> <\/label>\n<\/p>\n<p><label>Adres e-mail<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-173\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-173\" \/><\/span><\/label>\n<\/p>\n<p><label>Data<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-obecna\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text datepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date-obecna\" \/><\/span><\/label>\n<\/p>\n<p><div class=\"cf7mls-btns \"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-5\" style=\" \">Poprzedni krok<\/button><button type=\"button\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-5\" style=\" \">Nast\u0119pny krok<img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button><\/div><p><\/p><\/fieldset><fieldset class=\"fieldset-cf7mls\">\n<\/p>\n<h4>Krok 6 - Obowi\u0105zek informacyjny\n<\/h4>\n<ol class=\"agreements-list\">\n\t<li>\n\t\t<div>\n\t\t\t<p><strong>Administratorem Pani\/Pana danych osobowych jest:<\/strong>&nbsp;<strong>\u201ePOLSKI LEK \u2013 DYSTRYBUCJA\u201d Sp.&nbsp;z&nbsp;o.o.<\/strong>&nbsp;(podmiot odpowiedzialny) z&nbsp;siedzib\u0105 przy ul. Chopina 10, 34-100 Wadowice. Pani\/Pana dane osobowe b\u0119d\u0105 przetwarzane do cel\u00f3w zwi\u0105zanych z&nbsp;monitorowaniem bezpiecze\u0144stwa stosowania produkt\u00f3w leczniczych i&nbsp;b\u0119d\u0105 przekazywane w\u0142a\u015bciwym organom administracji publicznej. W&nbsp;sprawach zwi\u0105zanych z&nbsp;przetwarzaniem danych osobowych mo\u017ce si\u0119 Pani\/Pan kontaktowa\u0107 z&nbsp;<strong>Inspektorem Ochrony Danych Osobowych<\/strong>&nbsp;wyznaczonym przez Administratora na adres e-mail:&nbsp;<u><a href=\"mailto:leki@polskilek.pl\" target=\"_blank\" rel=\"noopener\">leki@polskilek.pl<\/a><\/u>&nbsp;lub na adres korespondencyjny Administratora danych osobowych.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p class=\"rodo-information rodo-1\">Pe\u0142na tre\u015b\u0107 obowi\u0105zku informacyjnego dotycz\u0105cego przetwarzania danych osobowych znajduje si\u0119 <a href=\"\/wp-content\/uploads\/2024\/07\/obowiazek-nr-1.pdf\" target=\"_blank\">tutaj<\/a>.\n\t\t<\/p>\n\t\t<p class=\"rodo-information rodo-3 active\">Pe\u0142na tre\u015b\u0107 obowi\u0105zku informacyjnego dotycz\u0105cego przetwarzania danych osobowych znajduje si\u0119 <a href=\"\/wp-content\/uploads\/2024\/07\/obowiazek-nr-3.pdf\" target=\"_blank\">tutaj<\/a>.\n\t\t<\/p>\n\t<\/li>\n\t<li class=\"patient-only\">\n\t\t<p>Je\u015bli w&nbsp;formularzu zosta\u0142y podane dane osobowe lekarza \u2013 prosimy o&nbsp;przekazanie mu za\u0142\u0105czonego <a href=\"\/wp-content\/uploads\/2024\/07\/obowiazek-nr-2.pdf\" target=\"_blank\">obowi\u0105zku informacyjnego dotycz\u0105cego przetwarzania danych osobowych<\/a>.\n\t\t<\/p>\n\t<\/li>\n\t<li class=\"rodo-information rodo-4 active\">\n\t\t<p>Prosimy o&nbsp;przekazanie osobie, kt\u00f3rej dotycz\u0105 zg\u0142oszone dzia\u0142ania niepo\u017c\u0105dane za\u0142\u0105czonego <a href=\"\/wp-content\/uploads\/2024\/07\/obowiazek-nr-4.pdf\" target=\"_blank\">obowi\u0105zku informacyjnego dotycz\u0105cego przetwarzania danych osobowych<\/a>.\n\t\t<\/p>\n\t<\/li>\n<\/ol>\n<hr \/>\n<p><label><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Wy\u015blij\" \/><\/label><br \/>\n<div class=\"cf7mls-btns cf7mls-btns-last-step\"><button type=\"button\" class=\"cf7mls_back action-button\" name=\"cf7mls_back\" id=\"cf7mls-back-btn-cf7mls_step-6\" style=\" \">Poprzedni krok<\/button><button type=\"button\" style=\"display: none;\" class=\"cf7mls_next cf7mls_btn action-button\" name=\"cf7mls_next\" id=\"cf7mls-next-btn-cf7mls_step-6\" style=\" \"><img decoding=\"async\" src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" alt=\"Step Loading\" data-lazy-src=\"https:\/\/polskilek.pl\/wp-content\/plugins\/cf7-multi-step\/assets\/frontend\/img\/loader.svg\" style=\"display: none;\" \/><\/button>\n<\/p><\/fieldset><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":140,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-450","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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