Personal Data Sharing Consent Form

Document code HE.FR.01 · Published 10/11/2017

This translation is provided for information only; the Turkish version is legally binding.

CAN SAĞLIK GRUBU

İZMİR ÖZEL CAN HASTANESİ

PERSONAL DATA SHARING CONSENT FORM

Doc. Code: HE.FR.01
Publication Date: 10/11/2017
Rev. No/Date: 00
Page Count/No: 1/1

In order to protect maternal and infant health, minimise mortality rates and ensure effective and periodic monitoring of pregnancy, I consent to my personal and pregnancy-related information being sent to the Health Directorate so that it can be forwarded to my family physician.

(CONSENTING PARTY)

Patient Name and Surname:
Date:
Signature:

You can print and sign the form and hand it in at our hospital.

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