Patient Declaration
Declaration and Consent
I declare that the information contained in the Information and Consent Form regarding the Protection of Personal Data has been explained to me clearly, accurately, and comprehensibly.
Information Status
Explained to me
Not explained to me
Your Choices Regarding Marketing and Communication
I CONSENT to the use of my personal data
for marketing activities, informational messages,
promotions, surveys, invitations, events, and communication
activities, and to being contacted via SMS, e-mail, post,
telephone, and other communication channels.
I DO NOT CONSENT.
Patient and/or Parent / Legal Guardian
Full Name
Signature
Date ____ / ____ / 20____