QUESTIONNAIRE

Personal data protection

COMPLETE YOUR PERSONAL DATA:

GENDER:

ManWoman

PLEASE SELECT IF YOU ARE SUFFERING FROM:

Rheumatologic arthritisAstrmy / COPDHeart diseasesIncreased cholesterolDiabetesKidney diseaseMultiple sclerosisFrequent diarrheaTreated depression

FOR PREVENTIVE VACCINATIONS:

I am interested in prophylactic vaccination

REGULATIONS

By completing this survey, I consent to the processing of my personal data, including sensitive data, within the meaning of the Act of 29 August 1997 on the Protection of Personal Data (Journal of Laws of 2002 No. 101, item 926, as amended) for to protect health, provide medical services and conduct medical scientific research carried out by the PI-House Clinical Research Center with headquarters in 80-546 Gdańsk, ul. Na Zaspa 3 - as an organizer of preventive action and personal data administrator and as a medical research provider.

What kind of contact from our site you prefer:
Telephone conversation - please mark Consent I + Consent III
E-mail, sms - please mark Consent II + Consent III

Consent I - I agree to the processing of my personal data by Centrum Badań Klinicznych PI-House Sp. z o.o. with headquarters in Gdańsk (80-546), ul. Na Zaspa 3 (contained in the above form) for marketing activities related to the subject of clinical trials. (only by post)

Consent II - I agree to receive information on my e-mail address or my mobile phone number from Centrum Badań Klinicznych PI-House Sp. z o.o. with headquarters in Gdańsk (80-546), ul. Zaspa 3 commercial information by e-mail.

Consent IV - I agree to the processing of my personal data by Centrum Badań Klinicznych PI-House Sp. z o.o. with headquarters in Gdańsk (80-546), ul. At Zaspa 3 for the purposes of carrying customer satisfaction surveys, carrying qualitative research, analytics, statistics, market research on the products and services of the Data Administrator.