Informed consent of the patient for the provision of health services

I have been clearly informed by my doctor about my medical condition, the nature of my illness and its expected course.

I have been clearly informed by my doctor about the proposed individual treatment, its purpose, nature, expected benefits, success, possible consequences and alternatives (other options) and I fully agree to this proposed treatment.

I have been clearly informed by my doctor about the possible risks associated with the treatment, the possible limitations in my usual way of life, ability to work, my medical capacity, after and during the treatment and the possible effect of the treatment on third parties (partner, family, friends, work team…).

I have been given information about the treatment regime, the rules of treatment, the preventive measures that are appropriate, the financial circumstances of the treatment and the expected duration of the treatment and how it will end.

I declare that I have been informed of my right to ask questions and to decide freely whether or not I agree with the proposed treatment. I declare that I understand all the information, have no further questions or uncertainties and give my free informed consent to the treatment.

I acknowledge that information about my health may be given to persons who will personally care for me in such cases where my health or the nature of my illness requires the information to be given. Only such information will be given to such persons not under my care as is necessary to ensure my care and protect my health.

Consent to the processing of personal data:

I declare that I consent to the processing of my personal data (name, surname, birth number, address, telephone number, medical records kept about me) in accordance with Regulation (EU) No 2016/679 of the European Parliament and of the Council on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (General Data Protection Regulation), Act No 372/2011 Coll., the Health Services Act and other related regulations.