PATIENT CONSENT TO PROCESSING PERSONAL DATA

    I hereby provide explicit and unambiguous consent to KCM Clinic S.A. for the processing of my data, as defined in the Act of April 27, 2016, regarding the protection of natural persons about the processing of personal data and the free movement of such data, and repealing Directive 95/46/EC GDPR (General Data Protection Regulation) Regulation (EU) 2016/679 of the European Parliament and the Council.

    YESNO

    Part A - Basic data

    Sexfemalemale

    Family name

    First name

    Date of birth

    Age

    Phone

    Email

    Height in centimeters

    Current weight in kilograms

    Max weight in kilograms in past

    BMI

    Part B - Medical information and history 1/3

    Planned Treatment

    Have you undergone surgery on the esophagus, stomach, duodenum or bowel? yesno

    If yes, which kind of surgery and when?

    Have you been diagnosed with:

    Diseases of the esophagus, stomach, duodenum or intestines/ bowel? yesno

    Difficulty in swallowing yesno

    Stenosis of the esophagus yesno

    Stenosis of the stomach yesno

    Pancreatitis yesno

    Inflammatory diseases of the intestines (colitis ulcerosa, Crohn's disease, others) yesno

    Intestinal stenosis, obstruction or ileus yesno

    Stomach or duodenum ulcer diseases yesno

    liver failure yesno

    Cancer disease yesno

    Heart failure yesno

    Part B - Medical information 2/2

    Medications/treatments

    Do you use blood-thinning medications? yesno

    Have you had a gastroscopy or colonoscopy in the last year with pathological result? yesno

    Do you currently suffer from:

    Stomach pain yesno

    Heartburn, reflux, burning in the sternum yesno

    In women:

    Are you pregnant or breastfeeding? yesno

    Part C - Additional personal and contact details

    Zip code

    City

    Country

    Adress

    Preferred contact time