Medical assessment request

Contact details of the person

First Name:

Last Name:

Phone No.:

Email:

Relationship to Patient:

Diagnosis and current condition:

Attach patient's medical report in pdf, jpg

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Consent to data processing

By completing and submitting the web form, in connection with an appointment for the provision of health care and/or services, I acknowledge that AXIS Rehab Ltd, IČO: 53 215 796, 8. mája 2800/1, Piešt'any 921 01, registered in the Commercial Register of the Trnava District Court, Section: Ltd., Insert No.: 47347/T processes my personal data in the scope of name, surname, date of birth, telephone number, email address, medical report, health insurance company for the purpose of making an appointment to a specialized outpatient clinic in § 13 par. 1 (b) and (f) and § 16 (2) (h) of Act No. 18/2018 Coll. on the Protection of Personal Data and Regulation (EU) 2016/679 of the European Parliament and of the Council. The legal basis for the processing of personal data is the performance of the contractual relationship between AXIS Rehab s.r.o. as a healthcare provider and the patient, as well as the legitimate interest of AXIS Rehab s.r.o., in particular in connection with the reporting of healthcare to health insurance companies and the maintenance of medical records. My personal data will not be disclosed or provided to third countries. Personal data will be kept during the provision of healthcare and for the period of necessary archiving in connection with the obligation to keep and maintain medical records. If AXIS Rehab s.r.o. has my phone number on record, it will send me a text message reminder of the appointment up to 7 working days before the appointment with a request to confirm the appointment. If AXIS REHAB S.R.O. does not know my phone number but knows my email address, it will send an email reminder of the appointment within 7 working days before the appointment with a request to confirm the appointment. I also confirm that I have been informed in particular of the contact details of the responsible person who carries out data protection activities on behalf of AXIS Rehab s.r.o., who is: Mgr. Michal Kaliak, workplace Záhradnícka 46/A, 821 08 Bratislava, contact: , and my right to access my personal data, delete my personal data (unless this right is in conflict with the obligation of AXIS Rehab s.r.o. to keep and store the patient's personal data as part of the medical documentation), to restrict the processing of personal data, to object to the processing of personal data, to the right to the portability of personal data as well as the right to file a petition with the Office for Personal Data Protection to initiate proceedings in the event of a violation of personal data protection rights.

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