Written consent to the processing of personal data

I, the undersigned _________________________________________________________________________________

residing at: ______________________________________________________________________________,

passport _________________________ issued ________________________________________________, in accordance with the requirements of Article 9 of the Federal Law of July 27, 2006 “On Personal Data” No. 152-FZ, I confirm my consent to the treatment by the SPA and the Medical Center LLC “Old Quarters”, Pskov, . Verkhne-Beregovaya, 4 (hereinafter - the Operator) of my personal data, including: last name, first name, patronymic, gender, date of birth, address of residence, contact (s) phone number (s), information about my health, diseases, treatment cases medical care - for medical and preventive purposes, in order to establish a medical diagnosis and provide medical services, provided that they are processed by a person who is professionally engaged in medical activities and is obliged to keep medical confidentiality. In the process of rendering medical assistance to the Operator by me, I grant the right to medical workers to transfer my personal data containing medical secrets to other officials of the Operator in the interests of my examination and treatment.

I give the operator the right to carry out all actions (operations) with my personal data, including collection, systematization, accumulation, storage, update, change, use, depersonalization, blocking, destruction. The operator has the right to process my personal data by entering it into an electronic database, listing it (lists) and reporting forms.

The period of storage of my personal data corresponds to the period of storage of primary documents (medical card) and is twenty-five years for a hospital, five years for a polyclinic.

The transfer of my personal data to other persons or their other disclosure can only be done with my written consent.

This consent is given by me ______________________________________________________________________________________________________________________

and acts indefinitely. I reserve the right to withdraw my consent by drawing up a corresponding written document, which can be sent to the Operator by registered mail with a letter of acknowledgment of receipt or in person on receipt to the Operator’s representative.

In case of receipt of my written application for withdrawal of this consent to the processing of personal data, the Operator is obliged to stop processing them during the period of time necessary to complete the settlement of payments for the medical care provided to me before.

Contact (e) telephone (s) and postal address ______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of the subject of personal data _____________________