CHILD’S BIRTH SELF-DECLARATION AND APPLICATION TO REGISTER WITH A PEDIATRICIAN
(Art. 46 - letter h - D.P.R. 28 December 2000, n. 445)

The undersigned parent

Applicant’s surname

Applicant’s name

Applicant’s tax code

Applicant’s date of birth

Applicant’s residence (Enter full address)

Applicant’s E-mail

Applicant’s telephone number

Applicant’s Identity Card

Any other attachment

Aware of incurring criminal penalties in the event of a false declaration pursuant to art. 76 D.P.R. n. 445 of 28 December 2000 and, forfeiting all benefits, under his/her own responsability

DECLARES

that his/her son/daughter

Surname

Name

Born in

Province

Resident in:

n°

City

Province

Nationality

Tax code

Would like to choose the following Pediatrician

Doctor 1

Or, if the Doctor has already exceeded his/her maximum number of patients

Doctor 2

If the chosen doctor is already treating a family member under the age of 14 (same residence as yours) please enter the family member’s name, surname, date of birth and tax code, for the purposes of family reunification.

Brother’s / Sister’s data

DECLARATION ACCORDING TO PRIVACY REGULATION

I have read the privacy policy on personal and health data treatment in AULSS 3 Internet site at the following link https://www.aulss3.veneto.it/privacy and I agree to my personal data treatment for administrative purposes, according to the European Regulation (GDPR n. 2016/679) and Italian Privacy Code (D.Lgs. n. 196/2003, as amended and supplemented by D.L. n. 101/2018).

READ AND AGREED

CHILD’S BIRTH SELF-DECLARATION AND APPLICATION TO REGISTER WITH A PEDIATRICIAN (Art. 46 - letter h - D.P.R. 28 December 2000, n. 445)

CHILD’S BIRTH SELF-DECLARATION AND APPLICATION TO REGISTER WITH A PEDIATRICIAN
(Art. 46 - letter h - D.P.R. 28 December 2000, n. 445)