My personal information
Name*:  
Last name*:  
Tax code (or Personal ID number):

How to contact me* ( )
Phone :
Mobile phone :
Email :

Reason for examination request
Problem**:
Click on the preferred day/days
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Click on the preferred Timeframe/Timeframes
9.00-11.0011.00-13.0013.00-15.0015.00-17.0017.00-19.00

* Obligatory fields
Disclosure according to the art. 13 of the Regulation (EU) 2016/679.
According to the art.13 of the Regulation (EU) 2016/679 on the protection of individuals with regard to the processing of personal data, as well as the free movement of such data, the undersigned Data Controller informs you of the following:
I. Legal basis and purpose of data processing. The processing of your personal data inserted in the form is based according to the art. 6 and 9 of the Regulation (EU) 2016/679 on your consent, that is the legitimate interest of the undersigned Data Controller to defend his rights in any litigation, and has the purpose of carrying out the activity you requested, by compiling and sending the form, that corresponds to the booking of an appointment.
II. Data processing methods. The processing of data will be based on principles of fairness, lawfulness and transparency and can be done by manual, computerized and telematic means, on paper and/or digital media. The data processing will be carried out in order to ensure the security and confidentiality of the data.
III. Recipients of personal data. Your personal data may be processed, taking into account and in compliance with professional secrecy, by Representatives of the Data Controller, duly identified and trained.
IV. Data retention period. Your personal data will be kept for a maximum of six months after the appointment date you requested; after this deadline, if not regulated by future consents, your personal data will be canceled.
V. Consent of the interested party. The processing of your personal data, as described above, is compulsory in order to carry out the appointment booking activity you requested by the compilation of the form. By filling in and submitting the form you agree to the processing of your data under the conditions set out in this disclosure.
VI. Rights of the interested party. The Regulation (EU) 2016/679 with reference to personal data gives you specific rights, among which we mention in a non-exhaustive way those to request access to personal data and the correction or cancellation of data, or the limitation of processing that concern them or to oppose to the processing itself, as well as the right to receive your personal data in a structured format of common use and legible by an automatic device (right to data portability). This Regulation also grants you the right to lodge a complaint with a Supervisory Authority, as well as the right to withdraw consent to the processing.
VII. Data Controller and Data Protection Officer
The Data Controller of your data is the natural person and/or the legal entity in the homepage of the website from which you have downloaded this disclosure.

**Attention! For the protection of privacy and in compliance with the reference legislation, this form is not compatible with the insertion of sensitive data. We therefore ask you NOT to enter data in the field “Problem” related to your specific health status and/or other sensitive data. Conversely, you are allowed to include general terminology, such as "request for tooth cleaning" or "caries search", etc.
Do you accept?*  
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