Patient Data

First Name (required)

Last Name (required)

Nationality (required)

ID/Passport (required)

Marital Status (required)

Date of Birth (required)

Address (required)

Postal Code (required)

Province (required)

Phone (required)

Email (required)

How did you first hear about our center? (required)
---Doctor *Friend / FamilyWebFacebookInstagramGoogleOthers

* Enter Doctor's name if applicable

Partner's Data (if applicable)

First Name

Last Name

Male/Female
---MaleFemale

Nationality

ID/Passport

Marital Status

Date of Birth

Address

Postal Code

Province

Phone

Email

I agree to receive information by email
I agree that my data may be processed under the terms and purposes indicated in this form

Data Protection Information

Prolonga Fertilidad, S.L. will process your data in order to provide the requested clinical services and manage your relationship with the clinic. The legal basis for processing is the provision of healthcare services, in accordance with Article 9.2(h) of the GDPR and Article 6.1(b) of the GDPR.

Data will only be shared with partner companies when necessary to deliver the contracted services and to comply with legal obligations.

Your data will be retained for as long as necessary to fulfill the purpose of processing and for the legally required retention periods.

You may exercise your rights of access, rectification, erasure, objection, portability and restriction of processing by contacting our Data Protection Officer at: dpd@fertty.com

You are also informed of your right to lodge a complaint with the supervisory authority (www.aepd.es) if you consider that the processing does not comply with applicable regulations.

Where applicable, you declare that you have informed your partner and obtained their consent to provide their personal data to the clinic for the purpose of managing an appointment and receiving the requested medical care.

By submitting this form, you acknowledge that you have been informed about the processing of your personal data.