Patient Registration

Patient Data

First Name (required)

Last Name (required)

Nationality (required)

ID/Passport (required)

Marital Status (required)

Date of Birth (required)

Place of Birth (required)

Occupation (required)

Education (required)

Address (required)

Postal Code (required)

Province (required)

Phone (required)

Email (required)

How did you first hear about our center? (required)

* Enter Doctor's name if applicable

Partner's Data (if applicable)

First Name

Last Name

Male/Female

Nationality

ID/Passport

Marital Status

Date of Birth

Place of Birth

Occupation

Education

Address

Postal Code

Province

Phone

I agree to receive information by email
YesNo

I agree that my data be processed in the terms and purposes indicated in this form

Privacy Policy Information

Treatment manager:

FERTTY (Prolonga Fertility CIF B66769258, SLP)

Purpose of treatment:

The data will be used for the provision of clinical services, administrative management and provision of additional information related to the services of the center.

Legitimacy of treatment:

Consent of the interested party.

Recipients

The data will be transferred to other collaborating companies, in order to complete the provision of the contracted services

Rights

At any time, you may exercise your rights of access, rectification, suspension, opposition to portability and limitation of processing by contacting FERTTY, C/Ausias Marc, 25. 08010 Barcelona.

Data retention time

The data will be retained for the periods established in the applicable regulations, in particular in Law 21/2000 on the rights to information concerning patient health and autonomy, and clinical documentation.

DPD (Data Protection Delegate)

The address of our DPD is dpd@fertty.com.

Additional information

You can find further and detailed information about Data Protection on our website privacy policy