RELATIVES

PERSONAL DATA OF FAMILY MEMBERS OF PATIENTS UNDER CARE OF FUNDACIÓN CUDECA
Your personal data are recorded in this form, as a relative of a patient who is going to be cared by the CUDECA Hospice Foundation. We are going to ask you to register a patient document so that we can know whose relative you are. You can save the form and continue later
PATIENT DOCUMENTATION
Please provide us with the identity information of the patient so that we can link you to the right patient
Please tell us the ID of the patient*
- DNI o SPANISH NIF
- NIE (identification document of foreign residents in Spain)
- PASSPORT
- I DO NOT HAVE DOCUMENTATION
Number of spanish DNI-NIF*
Write only numbers and letters, do not use spaces, slashes or hyphens.
NIE number (identification document of foreign residents in Spain)*
Write only numbers and letters, do not use spaces, slashes or hyphens.
Passport number*
Write it the same as it appears on the original passport
It is very important to have some type of document that identifies your relative, there are procedures that make it essential

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YOUR PERSONAL DATA
Now we will ask for your personal data
Name and family names*
This field is required. Write the same as it appears on your identity document.
Name Surnames
Please select your ID number*
- DNI o SPANISH NIF
- NIE (identification document of foreign residents in Spain)
- PASSPORT
- I DO NOT HAVE DOCUMENTATION
Number of spanish DNI-NIF*
Write only numbers and letters, do not use spaces, slashes or hyphens.
NIE number (identification document of foreign residents in Spain)*
Write only numbers and letters, do not use spaces, slashes or hyphens.
Passport number*
Write it the same as it appears on the original passport

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- Type of relationship with the patient
- Are you the primary caregiver for the patient?
  - Yes
  - No
- Are you the primary contact person for the patient?
  - Yes
  - No
- Genre
- Country of birth
  Country of birth
- Date of birth
  You must use two figures for the day, two for the month and four for the year, for example: 03/06/1970
  Date Format: DD slash MM slash YYYY
Your address
In the address specify in this order: Type of street: Street, Road, Avenue, Square, etc. -- Name of the street -- Number of the street -- Details of the dwelling, if any: portal, floor, etc.

Street Address Address Line 2 City State / Province Zip / Postal Code Country
- Your telephone number*
- Another telephone number
Your E-mail
Do you have any further comments?
Please add any questions or comments you may have.

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Legal agreements
In this last part we ask for your consent to the use of the personal data that we have requested from you
ACCEPTANCE OF CUDECA HOSPICE PRIVACY POLICY*
I accept the privacy policy of the Cudeca Hospice Foundation.
Our privacy policy is available in this link: Privacy policy - Cudeca Cancer Care Hospice
CONSENT FOR THE ASSIGNMENT OF PERSONAL DATA TO CUDECA*
I consent to the use of my personal data by Cudeca Hospice Foundation.
Text available in this link: CONSENT FOR THE ASSIGNMENT OF PERSONAL DATA TO CUDECA
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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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PERSONAL DATA OF FAMILY MEMBERS OF PATIENTS UNDER CARE OF FUNDACIÓN CUDECA