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Consenso al trattamento dei dati

  art. 7 Regolamento (UE) 679/2016

·         Dati dell’interessato

 

Cognome e nome    &COGNOM                                                                                                                                                                            

Luogo di nascita      &LUONAS                                                                                                                                                                                                                                                                        

Data di nascita         &DATNAS                                                                                                                                                                                                                         

(Qualora l’interessato sia minore di anni 16 o incapace)

·         Dati dell’esercente la potestà genitoriale / legale

Nome e cognome ________________________________________________________________

Luogo e data di nascita ____________________________________________________________

dichiara

- di aver letto e compreso l’informativa  resa dai contitolari del trattamento;

- di aver preso atto nell’informativa dei diritti che la legge riserva all’interessato, enucleati dall’art. 15 al 22 del Regolamento 679/2016 ;

- di aver compreso che il trattamento concerne i dati personali e sensibili;

- di aver preso atto che il consenso sarà valido sino ad eventuale  revoca da parte dell’interessato

presta il consenso

(obbligatorio ai fini dell’esecuzione della prestazione)

al trattamento dei dati necessari allo svolgimento della prestazione sanitaria ed alla comunicazione ai soggetti evidenziati nell’informativa.

                                             SI                                     NO

Data         &DATACC                                                                                                                                                             

 

                                                                                   Firma dell’interessato _______________________

&FINE                      

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