Medical Evaluation
Medical Evaluation

THE THREE PRELIMINARY STEPS

0 – READ OUR PRIVACY POLICY

1 – FILL OUT THE MEDICAL HISTORY FORM

2 – FILL OUT THE INFORMED CONSENT FORM

STEP 1 - MEDICAL HISTORY FORM

TO BE FILLED OUT BEFORE SHIPPING YOUR BLOOD SAMPLE OR RECEIVING THE PROGRAM YOU ASKED FOR

Dear Patient,

As first step before receiving any type of medical service from us, we kindly ask you to fill out the following medical history form. 

If not done in advance, please attach any blood work or test results as well as any medical examination in your possession, alternatively send them by email to: [email protected]

IMPORTANT! IF YOU ARE TAKING A PRODUCT OR SUPPLEMENT PLEASE, PUT A SAMPLE OF EACH ONE (LABELED WITH ITS NAME) INTO THE PARCEL TOGETHER WITH THE BLOOD SAMPLE. 

























    - Consent to informative communications (optional):

    The Center periodically sends insights on specific aspects related to health, practical advice directly suggested by its professionals and updates on the services provided.

    You may withdraw your consent at any time.

    -Privacy Policy consent* (Necessary to fulfill your request as patient):

    Pursuant to art. 13 of GDPR 679/2016 (General Data Protection Regulation) and our corporate Privacy Policy, we inform you that by submitting this form you authorize Biomedic to process personal data you have provided in the manner and terms of the information provided.

    I declare to have read and acknowledged the Privacy Policy.

    THIS FORM IS DIGITALLY SIGNED

    (The signature is applied by the system, generating a pair of RSA keys, attributed to each module.
    By checking the hash and signature, it will be possible to verify that the emails have actually been sent from the form and that the data transmitted by the user corresponds to what is recorded.)

    STEP 2 - INFORMED CONSENT

      Service requested: Integrative Medicine Program



      Health Director Biomedic Clinic & Research
      Dr. Elia Roberto Cestari

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      -Privacy Policy consent* (Necessary to fulfill your request as patient):

      Pursuant to art. 13 of GDPR 679/2016 (General Data Protection Regulation) and our corporate Privacy Policy, we inform you that by submitting this form you authorize Biomedic to process personal data you have provided in the manner and terms of the information provided.

      I declare to have read and acknowledged the Privacy Policy.

      THIS FORM IS DIGITALLY SIGNED

      (The signature is applied by the system, generating a pair of RSA keys, attributed to each module.
      By checking the hash and signature, it will be possible to verify that the emails have actually been sent from the form and that the data transmitted by the user corresponds to what is recorded.)

      PRIVACY POLICY

      USER INFORMATION PURSUANT TO GDPR 679/2016 – EX ARTT. 13-14

      (EUROPEAN PRIVACY REGULATION)

       

      In compliance with articles 13 and 14 of the GDPR 679/2016 (hereinafter Regulation), we inform you that this structure, in relation to the purpose of the treatments explained below, needs to process some of your personal data, including those “relating to health” – art. 4 p. 15). The treatment is carried out in compliance with the following conditions.

      1. Data Controller

      The data controller is Clinic & Research s. r. L. with headquarters in Via Belvedere, 11 – 22079 – Villa Guardia (CO); Tel: 031.928764; email: [email protected]

       

      2. Purpose of data processing

      The data processing is aimed at achieving the purposes of a private specialist service, following an express request by the interested party. The processing is carried out by means of the operations or set of operations indicated in art. 4 point Z) of the Regulation. The operations can be carried out with or without the aid of electronic or automated tools. Your data will be stored in paper archives or electronic databases at this facility. Your data will be protected from theft or alteration by means of special security, management and archiving systems. The staff of the structure will process your data only within the limits strictly necessary for the performance of their tasks and the services requested by you, and will protect its confidentiality by respecting the regulations in force. The treatment is carried out by the Data Controller, by external subjects as data processors, both as regards the health service and for the fulfillment of legal obligations; and by internal subjects appointed by the Data Controller to process your data.

       

      3. Nature of the provision of data and consequences in case of failure to provide data

      The provision of your personal data for the purposes highlighted in point 2 lett. A) of this information is mandatory and the refusal to provide such data prevents you from fulfilling your request.

       

      4. Transfer of personal data to countries outside the EU

      Your data will not be transferred to non-EU countries. The data will not be disseminated

       

      5. Data retention period

      Your data will be held by the structure for a period compatible with the obligations of keeping fiscal and health data.

       

      6. Rights of the interested party

      You have the right to withdraw your consent at any time; to request access to personal data and the correction or cancellation of the same or the limitation of the processing of personal data concerning him and to oppose their processing, in addition to the right to data portability; to lodge a complaint with the Italian Data Protection Authority, in the forms it deems necessary:

      – by e-mail, to the address: [email protected]

      – or by post to Clinic & Research s.r.l., based in Via Belvedere, 11 – 22079 – Villa Guardia (CO)

      CONSENT OF THE INTERESTED PARTY

      Having acquired the information provided by the Data Controller, pursuant to art. 13 of the GDPR 679/2016, in relation to the processing of personal data necessary for the purposes referred to in point 2 letters A) and B) of the aforementioned information, aware, in particular, that the processing will also concern the “health” data of referred to in art. 4 p 15) of the Regulations:

      by filling in and sending any of the FREE MEDICAL EVALUATION FORMS, MEDICAL HISTORY AND INFORMED CONSENT submitted through this website, you provide your consent.

      (In the event that the interested party cannot grant his consent due to impossibility, ability to act or ability to understand or want, the consent is given by the person who legally exercises the authority, or by a close relative, by a family member , by a cohabitant or in their absence, by the Manager of the facility where the person is staying).

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