TO COMPLETE
CONFIDENTIAL HEALTH INFORMATION BY
PATIENT
NAME: SURNAME:
DATE OF BIRTH*: AGE:
ADRESSE: CITY: CODE:
PHONE NUMBER*: e-mail*:
CONTACT IF EMERGENCY /GP/ …………………………………………………………….
PHYSICAL HEALTH STATUS YES NO ASSISTIVE DEVICE EXPLAIN
(IF APPLICABLE)
1
AUDITORY or VISUAL IMPAIRMENT
CARDIO-VASCULAR OR LUNG DISEASES
ALCOHOL
MOTOR IMPAIRMENT
EQUILIBIUM/DIZZINESS
MENTAL/ NEUROLOGIC DISEASES
OTHERS
□ ARE YOU ALLERGIC TO ANY MEDICATION? YES / NO [IF YES SPECIFY … ]
□ ARE YOU TAKING MEDICATION FOR High Blood Pressure? Diabetes? Asthma? OR OTHER
MEDICAL CONDITION ? YES / NO [IF YES SPECIFY NAME AND DOSIS OF THE MEDICATION]
MEDICAL REPORTS ? YES / NO [IF YES, PLEASE SEND A COPY]
In _______________, __________________of __________________2021
4/15/2021 CONFIDENTIALITY
PATIENT ACKNOWLEDGMENT AND AGREEMENT
Name: Surname: ID/PASSPORT:
In compliance with the provisions of EU/GDPR for the Protection of Personal Data, we inform you that the data
you provide will be incorporated and processed in the files owned by Mr. Tarik BAHJAWI [Doctor Line Spain] in
order to be able to provide you with our services, as well as to keep you informed about matters related to our
activity and services.
By signing this document, you give your express consent for Mr. Tarik BAHJAWI to use the data provided
by you for this specific purpose, agreeing to treat the personal data provided confidentially and not to
communicate or transfer said information to third parties. Likewise, we inform you of the possibility
that you have to exercise the rights of access, rectification, cancellation and opposition of your
personal data by writing to: 4doctor.line@gmail.com for the exercise of rights ………, accompanying a copy
of your ID.
I acknowledge that I have read and fully understand this consent form. I understand the risks
associated with the communication of email between the physician and me, and consent to the conditions
outlined herein, as well as any other instructions that the physician may impose to communicate with
patients by email. I acknowledge the physician’s right to, upon the provision of written notice,
withdraw the option of communicating through email. Any questions I may have had were answered.
Signature …………………..
