Declaration of consent for data transfer

 

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Name,                                  First name                                                                   Date of birth,                     SV number

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address

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I grant these below. Consents voluntary. I am aware that I can revoke this consent in whole or in part at any time without giving reasons and with effect for the future. 

 

Please tick the appropriate box and sign it at the end of the declaration.

 

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Transmission of patient data to other doctors or medical institutions

• I agree that my treating doctor, Dr. Shahzada Amir, Trillergasse 4/1/1, 1210 Vienna, may pass on my personal data (SV number, date of birth, address, diagnosis and related information) to other doctors or medical institutions in order to carry out medical examinations and findings in connection with to enable my current or future medical care.

 

• I agree that my treating doctor, Dr. Shahzada Amir, Trillergasse 4/1/1, 1210 Vienna, may pass on information in connection with my treatment to other doctors or medical institutions. If blood is taken in his practice, I agree to the transmission of my personal data for processing to Synlab, 1210 Vienna, rescue and, if necessary, other laboratories.

 

I give this consent voluntarily. I am aware that I can revoke this consent in whole or in part at any time without giving reasons and with effect for the future.

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Declaration of consent to disclose (in person or by telephone) medically relevant information

• I agree that my treating doctor, Dr. Shahzada Amir, Trillergasse 4/1/1, 1210 Vienna, can, at my request, discuss important medical information, treatment plans, etc. with those I trust.

• I allow information to be passed on to the following people:

 

• ………………………………………………………………………………………

• ………………………………………………………………………………………

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Declaration of consent for the collection of medically relevant documents

• I hereby authorize the following persons or service providers to collect medically relevant documents (e.g., prescriptions, referrals, etc.) on my behalf.

 

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Declaration of consent for sending emails

• I allow Dr. Shahzada Amir, my treating doctor in Vienna, sent my medical data and information from my patient file by email to ........................... ................................................ ............................@.................. ..........................................to pass on. This includes my health status, diagnoses, disease progression and treatment details, including medications.

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• I understand that unauthorized third parties may be able to access and modify this information.

 

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Location, date                                                                                      the patient's signature