Prescription request

Prescription requests for patients in the outpatient clinics of the Clinical Department of Pediatric Pneumology

Prescription request

Prescription requests for patients in the outpatient clinics of the Clinical Department of Pediatric Pneumology

Prescription request for the Clinical Department of Paediatric Pneumology, Allergology and Neonatology

Last Name: *

First name: *

Date of birth: *

gender: *

E-mail address: *

My phone number: *

Insurance status: *

I am a patient in the outpatient clinic/area of: *

My address:

Request text: *

Referral - Please upload a copy of your current valid referral from your GP or specialist. Please upload as PDF. (max. 20 MB; alternatively: image files are possible below):

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I have taken note of the information obligations (* see text below the form), which inform me in full about the use of the data provided via the contact form. *

I hereby confirm that I am not undergoing inpatient treatment or rehabilitation. *

Information requirements

I have taken note of the following information obligations, which fully inform me about the use of the data provided via the contact form: My personal data will be stored and processed on the server of the MHH data center in accordance with data protection regulations, in particular the GDPR. Access to the data is granted to authorized employees (e.g. medical assistants and medical staff of the Clinical Department of Paediatric Pneumology, Allergology and Neonatology).

Purpose of the data collection

The purpose of processing the personal data I provide is to contact me in order to clarify my concerns.

If I send files (images and documents) via this form, I give my consent to the processing of this data. This also applies to special categories of personal data transmitted by me, such as health data. These are processed by MHH in accordance with Art. 9 para. 2 lit. b) GDPR exclusively for your request.

Forwarding of the data

My personal data will be

within the MHH exclusively to those areas and persons who need this data to fulfill contractual and legal obligations or to implement the legitimate interest of the MHH.

Storage

My data will be stored by the MHH Clinical Department of Paediatric Pneumology, Allergology and Neonatology for as long as necessary to fulfill the purpose for which it was collected. As a rule, this means that my personal data will be deleted or anonymized once the request has been completed. Existing retention obligations and periods are observed.

Revocation

In the event of a revocation, my data that I have provided via the contact form will be deleted.

Legal rights

In the data protection information linked under the form, I have taken note of my legal rights with regard to the personal data concerning me in accordance with the GDPR.

Data protection information

Please read our data protection information to find out how we handle personal data and what your legal rights are: Click here for the data protection information.