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Patient Details
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| Gender |
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| Phone number on which you can be contacted * |
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Please add any information regarding the medical problem or diagnosis you want to request or reason for referral you think we should know before we reach out to you, in order to best deal with your request |
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| Personal data treatment consent |
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With reference to Legislative Decree n. 196/03, art. 13 (Law about personal data protection), we hereby inform you that your consent to the treatment of your personal data is required to allow you sending the filled referral form. Your personal data will be filed in our archives and processed both by paper and electronic format, in compliance with all the security and confidentially measures fixed by Law, Exhibit B. Your personal data may be transmitted to third party that should carry on all the necessary activities to manage your request. We inform you that the Data Controller is “GVM Care & Research S.p.a.”, with legal office in Lugo, Via Garibaldi n. 11 . We also specify that art. 7 of the Law attributes specific rights to citizens. In particular, you may obtain the access to your data or obtain their updating, correction, integration, deletion, the turning in anonymous form (if it is possible) or the blocking of any data treated in breach of the law. We should inform you that your refusal to authorize the use of your personal data will not allow us to carry out the requested services. |
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