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    GDPR Consent Form, ENG

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    muparila
    This document is a consent form for a patient to allow a gastroenterology outpatient clinic in Brno, Czech Republic to communicate personal health information via unsecured email or telephone. The patient provides their name, date of birth, contact email or phone number, and chooses a password. By signing, the patient acknowledges that email and phone are unsecured ways to transmit personal information but consents anyway. Communications will only use the clinic's official email address.

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    GDPR Consent Form, ENG

    Uploaded by

    muparila
    11 views1 page
    This document is a consent form for a patient to allow a gastroenterology outpatient clinic in Brno, Czech Republic to communicate personal health information via unsecured email or telephone. The patient provides their name, date of birth, contact email or phone number, and chooses a password. By signing, the patient acknowledges that email and phone are unsecured ways to transmit personal information but consents anyway. Communications will only use the clinic's official email address.

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    Original Title

    GDPR consent form, ENG

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    This document is a consent form for a patient to allow a gastroenterology outpatient clinic in Brno, Czech Republic to communicate personal health information via unsecured email or telephone. The patient provides their name, date of birth, contact email or phone number, and chooses a password. By signing, the patient acknowledges that email and phone are unsecured ways to transmit personal information but consents anyway. Communications will only use the clinic's official email address.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    11 views1 page

    GDPR Consent Form, ENG

    Uploaded by

    muparila
    This document is a consent form for a patient to allow a gastroenterology outpatient clinic in Brno, Czech Republic to communicate personal health information via unsecured email or telephone. The patient provides their name, date of birth, contact email or phone number, and chooses a password. By signing, the patient acknowledges that email and phone are unsecured ways to transmit personal information but consents anyway. Communications will only use the clinic's official email address.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    Zahradníkova 2 +420 541 552 293 zahradnikova@gastroenterologie-brno.

    cz
    Brno, 602 00 +420 724 723 716 www.gastroenterologie-brno.cz

    CONSENT TO THE MANNER PERSONAL INFORMATION IS DISCLOSED

    Basic patient information


    Name and surname: ______________________________
    Date of birth: ______________________________

    I agree with the communication by e-mail or telephone when it comes to transmission of


    prescriptions, information about my health and obtaining the results of examinations. I am aware
    that this is an unsecured way of transmitting personal information.

    To find out the above information, I will contact the outpatient clinic via my
    □ e-mail _____________________________________________________________
    □ telephone __________________________________________________________
    To verify my identity and reduce the risk of personal data leakage, I will use
    □ a password _________________________________________________________

    I will only use the outpatient clinic's e-mail zahradnikova@gastroenterologie-brno.cz

    In Brno on: ___________________________ Your signature: ______________________________


    -----------------------------------------------------------------------------------------------------------------------------------------------------------

    Zahradníkova 2 +420 541 552 293 zahradnikova@gastroenterologie-brno.cz


    Brno, 602 00 +420 724 723 716 www.gastroenterologie-brno.cz

    CONSENT TO THE MANNER PERSONAL INFORMATION IS DISCLOSED

    Basic patient information


    Name and surname: ______________________________
    Date of birth: ______________________________

    I agree with the communication by e-mail or telephone when it comes to transmission of


    prescriptions, information about my health and the obtaining of results of examinations. I am aware
    that this is an unsecured way of transmitting personal information.

    To find out the above information, I will contact the outpatient clinic via my
    □ e-mail _____________________________________________________________
    □ telephone __________________________________________________________
    To verify my identity and reduce the risk of personal data leakage, I will use
    □ a password _________________________________________________________

    I will only use the outpatient clinic's e-mail zahradnikova@gastroenterologie-brno.cz

    In Brno on: ___________________________ Your signature: ______________________________

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