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 - Personal information

    Genderfemalemale

    Family name

    First name

    Date of birth

    Age

    Phone

    Email

    Height in centimeters

    Weight in kilograms

    Part B - Medical information and medical history 1/3

    Planned treatment

    AIDS / HIV yesno

    Viral Hepatitis A,B,C,D,E,G yesno

    Blood clotsyesno

    Bleeding problemsyesno

    High blood pressure yesno

    Breathing problemsyesno

    Chest pain / heart attackyesno

    Irregular heartbeat yesno

    Other heart problems, if any, please list them

    Canceryesno

    Strokeyesno

    Epilepsyyesno

    Arthritis yesno

    Anemiayesno

    Asthmayesno

    Diabetesyesno

    What diabetes medications are you taking?

    Nasal / throat problems yesno

    Kidney problems yesno

    Liver problems yesno

    Stomach problems yesno

    Thyroid problems yesno

    Part B - Medical information and medical history 2/3

    Have you ever smoked cigarettes? yesno

    How much are you smoking now?

    In the past 18 months, have you been hospitalized, undergone surgery, or received medical care for any reason, including inpatient or outpatient hospitalization, outpatient surgery, or during childbirth? For what reason?

    Date

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

    Do you have tattoos? yesno

    Do you have earrings? yesno

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

    What is your average blood pressure?

    Part B - Medical information and medical history 3/3

    Are you allergic to any medication?yesno

    List all medications to which you are allergic

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

    Are you taking anticoagulants such as Coumadin®, Heparin®, Acenocoumarol®, Clopidogrel®, Xarelto®, Pradaxa® or daily aspirin? If so, when was your last dose?

    List all medications you are currently taking along with dosage

    What conditions are these drugs taken for?

    Do you suffer from chronic diseases?yesno

    Additional important information about your medical history:

    Approximate date of arrival

    Part C - Additional personal and contact information

    Address

    City

    Country

    Preferred contact time