Individual test assignment service
is aimed both for both patients registering for first appointment with dr. Cubala*, as well as people only interested in performing tests. More information regarding the first visit can be found in Regulations. We sincerely ask you to become acquainted with it.
*Applies to patients with symptoms of, diagnosed, or suspected autism. Patients with other diseases are asked to contact us at firstname.lastname@example.org.
Before beginning, we ask that you familiarize yourself with the Regulations, where you will find detailed instructions for filling out the questionnaire (section 1 of the Regulations).
1. In order to begin the process, please download and fill out the questionnaire, according to Regulations – click here to download the questionnaire
2. Please email the following information to email@example.com, with the subject “Test assignment” or child’s full name:
– Questionnaire, properly filled out in Microsoft Word on a PC (with the exception of the last page, which should be filled out by hand)
– Consent form for the tests, filled out and signed
– Optionally: lab test results – only those differing from reference values (as a PDF file)
– Optionally: biomedical test results (metabolic urine analysis, comprehensive stool analysis, hair analysis) not older than a year (as a PDF file)
– Bank transfer confirmation, in the amount of 200 PLN (as a PDF or JPEG file)
3. Please send signed master copy of the consent for by a registered letter or bring it personally to: Arcana INTEGRATIVE MEDICINE, Kniaziewicza 45/10, 05-500 Piaseczno. The master copy must be received within 14 business days of sending the form.
Please do not send a printed questionnaire or test results – only the signed consent page.
The date of registration is considered as the day of emailing all required documents:
– filled out questionnaire
– scanned consent form
– and bank transfer confirmation.