FORM - Cudeca Cancer Care Hospice

PATIENT'S PERSONAL DETAILS
In this form we register personal data of a patient who is going to be attended by CUDECA Foundation. We will ask you for a photo of your identity documents, please try to have them ready.
- Name y Middle Name*
  This field is mandatory. Please enter the same as on your identity card.
  Name Middle name
- Last name
- Marital status
  - Married
  - Single
  - Widowed
  - Divorced
- Occupation
  - Retired
  - Self-employed
  - Employed person
  - Home worker
  - Disability pensioner
- Gender
- Number of children
  Please enter a number from 0 to 20.
- Country of birth
  Country
- Date of birth*
  You should use two digits for the day, two for the month and four for the year, e.g. 06/03/1970.
  Date Format: DD slash MM slash YYYY
Patient's address details
In the address specify in this order: Type of street: Street, Road, Avenue, Square, etc--Street name--Street number--Dwelling details if any: doorway, flat etc.

Address additional information from the directorate City Province Post Code Country
- Main contact telephone number*
- Other contact telephone number
E-mail
If you are going to use a family member's email address, it is best to have your family member fill in your form and enter the email address there.

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PATIENT DOCUMENTS
- Type of document to be used for registration
  - DNI or NIF
  - NIE
  - PASSPORT
  - I HAVE NO DOCUMENTATION
- DNI-NIF Number*
  Write only numbers and letters, do not use spaces, slashes or dashes.
- NIE Number*
  Write only numbers and letters, do not use spaces, slashes or dashes.
- PASSPORT Number*
  Write only numbers and letters, do not use spaces, slashes or dashes.
- Identity Document
  Upload a photo of your identity card here

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HEALTH CARE DATA
- Social security number
  Write only numbers, do not use spaces, slashes or hyphens.
- Social Security Document
  Upload here a photo of the Social Security Document
- NUHSA Number
  This is the Andalucía health history number, always starting with the letters AN. Write only numbers, do not use spaces, slashes or hyphens.
Medical Reports
Upload here a picture of the report you think is most important for your situation. You can upload only two files
Drop files here or
- Health Coverage*
  Tell us who your health coverage depends on so that we can better coordinate with you.
  - Public Health - SAS
  - MUFACE
  - ISFAS
  - MUGEJU
  - Exclusive Private Health Insurance
  - I have no Health Care
- Health Centre
- Details of your Health Insurance Company (Mutual Insurance Company for Civil Servants)
  You have indicated that you are a member of a health insurance company, please give us the name of the health insurance company that is treating you.
- Details of your Health Company
  If you only have private health care, please provide us with the name of your company and your policy number so that we can contact your company.
Do you have any further comments?
Please add any questions or comments you may have.

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LEGAL CONSENT
We are going to ask you to consent with two mandatory legal agreements: the privacy policy and the consent for the transfer of personal data. In casy you do not agree with then, we will not be able to record your personal data and our service will not be available.
CONSENT TO POLICY PRIVACY*
I agree to the privacy policy
Our privacy policy is available in this link: Privacy policy - Cudeca Cancer Care Hospice
CONSENT TRANSFER PERSONAL DATA*
I consent to the use of my personal data.
The full text of the consent to be signed is available at this link:
CONSENT FOR THE TRANSFER OF PERSONAL DATA
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LEGAL DISCLAIMER
In accordance with the provisions of the regulations in force on the protection of personal data, Regulation (EU) 2016/679 of April 27, 2016 (GDPR) and the Spanish Organic Law 3/2018 of December 5 on Data Protection and Guarantee of Digital Rights (LOPDGDDD), we inform you that FUNDACION CUDECA is responsible for the treatment of personal data for administrative, statistical and information purposes. You have the right to cancel, access, rectify, transfer or delete your data as well as the right to limit or oppose the treatment of said data, in which case you should contact FUNDACÍON CUDECA at Avda. del Cosmos, s/n 29631 Benalmádena (MÁLAGA), or e-mail: datos@cudeca.org. If you consider that the treatment of your data does not comply with current regulations you have the right to file a claim with the Data Protection Agency www.agpd.es

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PATIENT'S PERSONAL DETAILS