Blisko 300 punktów pobrań i pobrania w domu w całej polsce
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Blisko 300 punktów pobrań i pobrania w domu w całej polsce
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NIFTY pro survey

IMPORTANT: If on the day of sample collection the data provided in the survey changes, be sure to contact us to update the data.

    1. Name and surname*:  






    7. Weight and height*:




    Date of last dose:

    Transplant date:

    Term of therapy completion:

    Questions regarding the last 12 months
    (in case of a situation older than 12 months, please tick NO)

    Term of therapy completion:

    Term of therapy completion:

    Term of therapy completion:

    Term of therapy completion:

    Term of therapy completion:

    Term of therapy completion:

    Questions about the current pregnancy

    Date:

    I consent to the processing of my personal data in compliance with the provisions of Regulation (EU) 2016/679 of the European Parliament and of the Council of 27/04/2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and the repeal of Directive 95/46 / WE (Dz. Urz. UE L 2016, No. 119) in connection with the implementation of the order to register and publish the results of molecular tests. Providing data is voluntary, but necessary to process the order.

    The data includes: name and surname, correspondence address, telephone number, PESEL number, e-mail address, date of birth, health information, identity card or passport number. The data concerns the patient and his legal guardians, if necessary.

    I have been informed that I have the right to access my data and the possibility of correcting it. The administrator of personal data is TESTDNA sp. Z oo Sp.k., NIP: 634-282-27-48.

    *mandatory fields

    IMPORTANT: If on the day of sample collection the data provided in the survey changes, be sure to contact us to update the data.
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