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.

O vašem ekzému

Part 1 of 4

Tento formulář je určen pro dlouhodobý ekzém (atopickou dermatitidu), jehož charakter se v poslední době nezměnil. Nahrajte prosím jasnou fotografii postižené oblasti. Lékař ji potřebuje k posouzení závažnosti a rozsahu a k odhalení známek infekce. Pokud z vašich odpovědí vyplývá kožní infekce, rozsáhlé vzplanutí nebo možná akutní situace, můžete být místo vyřízení přes tento formulář odkázáni na neodkladnou péči nebo na videokonzultaci.

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

Eczema Treatment