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FORM

Home / FORM

Step 1 of 4 - Datos del Paciente

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  • 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.
    • This field is mandatory. Please enter the same as on your identity card.
    • Please enter a number from 0 to 20.
    • 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
  • 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.
  • 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

    • Write only numbers and letters, do not use spaces, slashes or dashes.
    • Write only numbers and letters, do not use spaces, slashes or dashes.
    • Write only numbers and letters, do not use spaces, slashes or dashes.
    • Upload a photo of your identity card here
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  • HEALTH CARE DATA

    • Write only numbers, do not use spaces, slashes or hyphens.
    • Upload here a photo of the Social Security Document
      • This is the Andalucía health history number, always starting with the letters AN. Write only numbers, do not use spaces, slashes or hyphens.
    • 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
      • Tell us who your health coverage depends on so that we can better coordinate with you.
      • 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.
      • 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.
    • 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.
    • Our privacy policy is available in this link: Privacy policy - Cudeca Cancer Care Hospice
    • The full text of the consent to be signed is available at this link:
      CONSENT FOR THE TRANSFER OF PERSONAL DATA
    • 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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