REGISTRATION CONSENT Step 1 of 2 50% Unique IDDATE(Required) DD slash MM slash YYYY NAME(Required) NAME UPDATE PATRONYMO DATE OF BIRTH(Required)DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AM PATIENT(Required) Patient Registration Number from the stickerMOBILE PHONE CONSENT TO THE CONDUCT OF THE EXAMINATION:(Required) BROGOSITY CASTING COLONOSCIENCE ERCP/ENDOSCOPIC SPHINCTEROTOMY DISTRICT MULTIPETOMY GASTROSTOMY PEG PLACEMENT Select the test(s) for which you give your consent after informing the doctor.THERAPON DOCTOR(Required)CHOOSE A DOCTORGAGALIS STARIOSKOUTSOUMOURAKIS ANASTASIOSPASCOS PASCALTHE SIGNATORY OF THE CONSENT IS:(Required) THE PATIENT HIMSELF RELATED NAME OF RELATIVES(Required) NAME UPDATE PATRONYMO ID number or ID number of the data file(Required) MAKING MEDICAL DATA AVAILABLE FOR RESEARCH PURPOSES I AGREEI agree to the use of my Medical Record for medical purposes, provided that my anonymity is respected and my personal data is respectedSIGNED CONSENT(Required)Form your signature within the frame using your computer mouse, stylus or finger. PREVIEWSee the details of the application you are about to submit. If you wish to correct or complete anything, click on the "Previous" button to return to the application.{all_fields}
