Personal data of a child
Permanent residence in the Czech Republic*
If the address is different, please give it below:*
* Fields marked with an asterisk are required for successful registration.
Do you consent to the provision of information about your child’s health, consulting your child’s medical records and making copies of your child’s medical records for other parties?
*
Choose which actions you consent to:
the provision of information about the child’s health:*
with granting the consent with the provision of health services if my health prevents me from expressing my opinion:*
the inspection of the child’s medical records and making copies of medical records:*
Form of providing information to the above persons:*
* Fields marked with an asterisk are required for successful registration.
Declaration
I confirm that I am aware of the right to receive information on the scope and price of the health services provided at MY CLINIC at any time. I confirm that I am familiar with the
Price List.*
I consent to MY CLINIC sending me information about news, events and the health services offered via email.*
I consent to MY CLINIC sending me satisfaction surveys via email.*
I agree to the sending of medical reports and laboratory results, accounting and payment documents to the above e-mail. I am aware of all the risks involved in electronic communication.
*
Please inform us of any appointment cancellation no later than 24 hours in advance. We would like to remind you that if you do not show up for your scheduled appointment without prior notice, or if you cancel less than 24 hours in advance, My Clinic reserves the right to charge you a flat fee of CZK 1,500 as compensation.
Protection of Personal Data
MyClinic s.r.o., as the Data Controller, collects and processes the personal data (including health data) that I have provided to the Data Controller or which the Data Controller has obtained from its own activities for the purpose of providing health services and fulfilling related legal obligations. The Data Controller is entitled and obliged to process this data in accordance with the law, in particular Act No 372/2011 on Health Services, performance of the contract with the data subject and on the basis of measures necessary prior to entering into the contract.
The personal data will be processed and stored for the duration of the above purpose and for the period specified by law, in particular Decree No 98/2012 on Medical Documentation.
Some personal data may be processed on the basis of your consent to the processing of personal data for specific purposes (e.g. sending offers). This consent is voluntary and you can withdraw it at any time, or exercise other rights associated with this processing.
In relation to the processing of personal data, you have, in particular, the right of access to personal data, the right to rectification if the personal data is inaccurate or incomplete, the right to erasure of personal data and to restriction of the processing of personal data in specified cases, the right to submit a complaint to the Office for Personal Data Protection, the right to withdraw consent if consent is the basis for processing, and the right to object in specified cases. Details of these rights, as well as how to exercise these rights, can be found at www.myclinic.cz or by contacting gdpr@myclinic.cz.
I am aware of the obligation to inform the Data Controller of any change in the data I provide in connection with the stated purpose or that the Data Controller processes about me.
Details on the processing of personal data by the Data Controller are available at www.myclinic.cz.
