PERSONAL DATA PROCESSING INFORMATION AND CONSENT DECLARATION FORM
I, the undersigned (Data Subject), hereby declare that I have been informed about the acts of collection, processing, and storage of my data and that I provide, in accordance with
the provisions of Articles 7 and 9 of the General Data Protection Regulation (GDPR / (EU) No. 679/2016, as well as the relevant applicable provisions transposing it into national
legislation), my explicit consent to the Company under the trade name COSMETIC DERMA MEDICINE IATRIKI SA, TIN EL 800412186, with registered office KONSTANTINOU VENTIRI 5 ‐ ILISIA, P.C. 11528, ATHENS and I accept that my personal data be collected, processed, and stored for the purposes cited below.
Data shall be mainly processed for Medical Record Keeping, in accordance with Article 14 of the Code of Medical Ethics. This shall include in particular:
a. Recording and maintenance of a medical history, examinations, and relevant information of any kind whatsoever;
b. Diagnosis and treatment of the patient;
c. Company’s compliance with obligations provided for in the applicable legislative and regulatory framework;
d. Research the Company may carry out in relation to other previous or future care provided to me.
a. The Company shall collect my personal data contained in the client registration application or the form describing my medical history, in supporting and other documents accompanying them, and any other data that I have personally communicated, or I will communicate to the Company in the future, either orally or by any other means, hardcopy or electronic, via its employees, doctors associated with it or any other person authorized by me.
b. Moreover, the Company shall request and collect, exclusively for the purposes set out in par. 1 hereof, data related to me from third parties, either associated with the Company or not, such as, indicatively, biochemical analysis laboratories, medical laboratories, associated doctors, etc.
The data to be processed by the Company fall within the following categories:
a. Identification data e.g. first and last name, date of birth, ID card/passport number, social security number, tax identification number
b. Contact data e.g. email address/address for correspondence, telephone/fax numbers
c. Payment data e.g. bank accounts, debit/credit and other banking cards
d. Medical data discomforts, allergies, reason for visit, primary and secondary diagnosis or treatment, results of clinical and paraclinical tests.
My data may be transmitted to:
a. Other medical laboratories for further diagnosis;
b. The Company’s headquarters, or another company established in the EU that is a member to the same group as the Company, for statistical purposes, without regard to any data falling within special categories;
c. Public/judicial authorities, legal advisors, inside or outside the EU.
The Company shall collect, store and, in general, process my data for a period of twenty (20) years at the latest from my last visit to the clinic.
I have been advised that I have the right to withdraw my present consent at any time, as well as of the consequences of such withdrawal. In particular, I have been informed that, in case of withdrawal of my consent for processing of data that are absolutely necessary for the provision of the treatment requested, then such provision shall not be possible.
Moreover, I have been informed about my rights cited below, as applicable under the conditions laid down in the General Data Protection Regulation (GDPR / (EU) No. 679/2016),
as well as the relevant applicable provisions transposing it into national legislation. More specifically:
Exercise of the above‐mentioned rights shall be conditional on the submission of a written application to the Company, free of charge, at the email address [email protected] . For any matter whatsoever, I can contact the Personal Data Protection Officer of the Company, by sending an email at [email protected] . In any case, I am entitled to contact the Personal Data Protection Authority either by mail (1‐3 Kifissias Ave., PC 115 23) or by e‐mail (www.dpa.gr).
If the relevant consent is not granted or is withdrawn, in whole or in part, the Company shall maintain the right to refuse and/or terminate the provision of any service, even plain information provision. Moreover, the Company shall maintain the right to keep records for reasons of protecting its legal rights and providing evidence before any judicial or administrative authority.
In case of exercise of any of the above‐mentioned rights, the Company shall take all reasonable measures to satisfy the relevant request within thirty (30) calendar days from receiving it, by notifying the person concerned in writing of its satisfaction, or of the reasons preventing such exercise.
I have been explicitly informed that the Company will collect, store, and process my data for implementing targeted marketing activities, or for sending company newsletters, or for the commercial promotion of products of the Company or of other companies of the same Group, or for purposes of surveys related to the quality of the services it provides.
For the above purpose, my data may be transmitted to associated companies that carry out surveys or implement promotional activities.
Within the context of the same processing, I have been advised of my right to object to such processing at any time, by sending a relevant request to the Company (email: [email protected]).
The Company has adopted a policy consistent with the Personal Data Protection Law, which gives you the right to control in the future the use of photographs or videos of you taken during your treatment.
Taking into account the explanations provided by the Company:
I have been advised of the above processing of my personal data and I CONSENT to it, as specifically laid down in this document.
For the Company
Personal Data Protection Department e‐mail: [email protected]
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