GP or Pediatrician revocation because temporary domiciled in another Region

The undersigned

Applicant’s surname

Applicant’s name

Applicant’s tax code

Applicant’s date of birth

Applicant’s residence (Enter full address)

City / Competent District

Applicant’s E-mail

Applicant’s telephone number

Applicant’s Identity Card

Any other attachment

Aware that pursuant to art. 76 of DPR 445/2000 the release of false declarations is punished according to the Criminal Code and special laws on the matter, on his/her own responsability

Asks for oneself and for the following under-18 relatives to revoke his/her GP or Pediatrician because temporary domiciled in another Region

Enter their name

Enter their names

Domicile

City

Address

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