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Preventive Examination Card

Dear Sir/Madam,

Basing on Article 13 of the Regulation of the European Parliament and of the Council (EU) 2016/679 of April 27th 2016 on the protection of individuals with regard to personal data processing and on the free movement of such data and repealing Directive 95/46 / EC (GDPR), we inform that :

1. Centrum Medycyny Rodzinnej GUMED Sp. z o.o. with seat in Gdańsk, ul. Dębinki 7, 80-211 Gdańsk is the administrator of the transmitted data.
2.  The purpose of processing your personal data is to perform tasks related to the provision of health services in accordance with the applicable law.
3. Your personal data are secured in accordance with applicable regulations, and their recipients may be entities authorized to disclose data to them under the law and entities that process personal data as part of the provision of services to the administrator.
4. It is not expected that your data will be transmitted to countries outside the European Economic Area or international institutions, nor will your  personal data be processed for a purpose other than the purpose for which personal data was collected.
5. Decisions regarding your personal data will not be taken in an automated manner.
6. Your personal data will be kept for the period resulting from the archiving classification.
7.  You have the right to: protect your personal data, to information about the rules of their processing, to have access to them and obtain a copy of them, to rectify them, to make a  complaint to the President of Personal Data Protection Office, remove or limit processing and notify each recipient about rectification or reduction of processing . You also have the right not to be subject to automated processing of your data, the right to contact the Data Protection Officer iodcmr@gumed.edu.pl and the right to compensation for damage to property or non-property as a result of the breach of the provisions of the GDPR.

PREVENTIVE EXAMINATION CARD
Identification data of examined person
PESEL Number (if applicable, if not ID Card number with date of birth)
Address of residence in Poland
Employer’s / educational institution's data
* In case of lack of employer’s /educational institution referral and information on harmful and hazardous factors, preventive examination should not take place.
Please specify, what kind ?
 Workplace / Employer (faculty)PositionPeriod of employment/studiesHazardous / onerous factorPeriod of employment at risk
1
2
3
4
5
Number from profesion diseases list
From which cause?
describe health consequences of this accident
level, cause (sign of disability):
PATIENT'S EXAMINATION
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In particular: allergies (asthma) , diabetes, mental diseases, heart diseases, hypertension and cancer
the number of cigarettes smoked per day:
the number of cigarettes smoked per day
Please select
EXAMINATIONS FOR EPIDEMIOLOGICAL PURPOSES
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