Information for women only: The intervention cannot be performed while the client is pregnant!
In case of doubt, it is necessary to perform a pregnancy test, or to visit a gynaecologist! By signing this document, the client declares that she is not pregnant for the purposes of performing the intervention. Blood clotting may be adversely affected during and just before menstruation, so it is recommended to plan the procedure for another period.
I declare that I have fully understood and answered all the above questions truthfully and completely. I had the opportunity to ask any question; all the questions I asked were answered. I understand the need to have a preoperative examination (blood tests, ECG and possibly others, as required by MEDICOM CLINIC doctor) and I acknowledge that without their presentation it will not be possible to perform the required intervention.
By signing this document, the client agrees that the MEDICOM CLINIC a. s., health care establishment with registered office in Prague 1 - Nové Město, Spálená 75/16, postal code 110 00, company ID: 247 56 148, registered under file no. No. B 16606 at the Municipal Court in Prague (hereinafter also referred to as the “data controller”), as the data controller pursuant to Act No. 110/2019 Coll., on the processing of personal data, as amended (hereinafter referred to as the “Personal Data Processing Act”), collects, stores and processes his/her personal data (including the sensitive ones), namely the following data: name, surname, personal identification number, address of permanent residence, telephone contact, e-mail contact, data kept in accordance with applicable laws in the client‘s medical records, health insurance company, exclusively for the purpose of subsequent intervention, resp. to keep medical records on it, whereas MEDICOM CLINIC a. s. will be the service provider and the data subject will be their recipient. The client declares that he/she has been informed of his/her rights pursuant to § 28 and § 29 of the Personal DataP rocessing Act. This means in particular that the provision ofp ersonal data to the data controller for this purpose is voluntary, that the data subject (client) has the right to access them, has the right to revoke the above consent at any time in writing at the controller‘s address (provided that the client acknowledges that in relation to each controller the consent must be revoked separately), and also has the right to contact the Office for Personal Data Protection in the event of a breach of its rights and to request appropriate redress. This redress can be, for example, refraining from such actions of the controller, removing the situation, providing an apology, making corrections or additions, blocking, liquidation of personal data, payment of monetary compensation, as well as the use of other rights arising from § 29 and § 32 of the Personal Data Protection Act. Data controller declares that it will collect personal data to the extent necessary to fulfil the specified purpose and process them only in accordance with the purpose for which they were collected. Employees of the data controller or other natural persons who process personal data on the basis of a contract with the data controller and other persons who will have access to personal data on the basis of this consent are obliged to maintain the confidentiality of personal data, even after their termination of employment or work. Personal data is fully secured against misuse.