Global Health

Patient details

Patient full nameEmailPhone

Date of birth

Enter a date up to 04/11/2026.

Identity

Rodné číslo

Your rodné číslo — it is also your health insurance number, and the doctor needs it to arrange electronic treatment.

Passport / ID card number

Required on Czech clinical records. Your rodné číslo stays optional.

Health insurance company

Your Czech public health insurer. The doctor needs it to arrange electronic treatment you can collect at any Czech pharmacy.

I have no Czech public health insuranceTick this if you are not in the Czech public system. You can still book — but Czech electronic treatment cannot be arranged, so any treatment will be private.

Vaše alergie

Part 1 of 4

Tento formulář je určen pro opakované recepty na adrenalinová pera (EpiPen, Jext nebo Emerade) pro známou těžkou alergii, která vám už byla diagnostikována.

Na co máte alergii a zhruba kolik anafylaktických reakcí jste prodělal(a)?

Vyšetřoval vás kvůli tomu někdy alergolog?

AnoNeNevím jistě

Kolik per s platnou dobou použitelnosti právě máte?

Žádáte o jedno pero, nebo o dvě?

DvěJedno

Máte zkušenost s použitím pera při skutečné reakci?

Nikdy jsem pero nepoužil(a)Ano, v posledních několika měsícíchAno, před delší dobou

Patient address

Required for medical documents and any physical materials.

Street addressApt / unit (optional)House number (č.p.)Orientation number (č.o.)

In an address written Rybná 716/24, 716 is the číslo popisné and 24 the číslo orientační. Either one on its own is enough.

CityPostal code

Review

Data sharing consent (GDPR)

I confirm the details above are accurate and consent to a video consultation with the selected clinician.Send me appointment updates via WhatsApp (optional)I consent to my personal and medical data being processed by Global Health and shared with its treating clinics and medical network — including clinics in other countries — for the purpose of my care, service improvement, and security. Privacy Policy

Anaphylaxis Treatment (Adrenaline Pens)