Other Surgery

PATIENT CONSENT TO PROCESSING PERSONAL DATA

I hereby give specific, unambiguous consent to KCM Clinic S.A. for processing my personal data as defined in the Act of April 27 2016 on the protection of natural persons with regard to the processing of personal data and on 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 OF THE COUNCIL.
YESNO

Sexmalefemale

Family name

First name

Date of birth

Country

Phone

Email

Height in cm

Weight in kg

Planned treatment

How much do you smoke now?

Within the past 18 months have you been hospitalized, had surgery or received medical care for anything including inpatient or out-patient, ambulatory surgery or delivery of a pregnancy? What reason? *

Date:

Please list all your past surgeries (with approximate dates):

Do you have any implants, screws or metal objects in your body such as pacemaker?yesno

What is your average blood pressure

Are you allergic to any medication?yesno

If there is an allergy to medicines, please specify to which ones

Do you take an anticoagulant such as Coumadin®, Heparin ®, Acenocoumarol, Clopidogrel, Xarelto, Pradaxa, or a daily aspirin? If yes, when was your last dose?

List all Medications you currently take with the dosage

What conditions are you taking the listed medications for?

Do you suffer from chronic diseases?yesno

Additional important information about your medical history:

Approximate date of your arrival

Address info:
Address
City
Country
Preferred contact time