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Chojnice, dn. …………….
Deklaracja zgody na przetwarzanie danych osobowych
Dane pacjenta:
Nazwisko ……………………………. Imię ………………………..
PESEL ……………………………….
Zakres danych:
nr telefonu:……………….…...................
adres e-mail:…………………………….
Ja niżej podpisany/a wyrażam zgodnie z art. 7 ust. 2 Rozporządzenia Parlamentu Europejskiego i Rady UE 2016/679 z 27 kwietnia 2016 r. wyraźną i dobrowolną zgodę na przetwarzanie i zbieranie moich danych osobowych przez
FizjoHome Indywidualna Praktyka Fizjoterapeutyczna Katarzyna Śliwicka ul. Młodzieżowa 25/8 89-600 Chojnice w
celu:
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