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The undersigned

Applicant's surname

Applicant's name

Applicant's tax code

Applicant's date of birth

Applicant's residence/domicile (Enter full address)

City / Competent District

Applicant's e-mail

Applicant's telephone number

Applicant's Identity Document

Any additional 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

Attach doctor revocation, if previously domiciled in another Local Health Authority

The applicant asks to CHOOSE for himself/herself

IF THE NEW DOCTOR BELONGS TO THE PREVIOUS DOCTOR’S ASSOCIATION, THE NEW DOCTOR’S CONSENT MUST BE ATTACHED, EXCEPT IN CASE OF TERMINATION OF YOUR PREVIOUS DOCTOR.

Attach doctor’s consent

Doctor 1

or, if the selected doctor has no more places available

Doctor 2

or, if the selected doctor has no more places available

Doctor 3

The applicant asks to choose for his/her CHILDREN (Under 18 years of age)

Add The applicant asks to choose for his/her CHILDREN (Under 18 years of age)

IF THE PEDIATRICIAN OR GENERAL PRACTITIONER BELONGS TO THE SAME ASSOCIATION OF YOUR PREVIOUS ONE, THE NEW DOCTOR’S CONSENT MUST BE ATTACHED, EXCEPT IN CASE OF THE TERMINATION OF YOUR PREVIOUS DOCTOR.

Attach doctor’s consent

Pediatrician or General Practitioner

or if the pediatrician or the General Practitioner has no places available,

Pediatrician or General Practitioner

or if the pediatrician or the General Practitioner has no places available,

Pediatrician or General Practitioner

If the selected doctor is already a family member’s or cohabitant’s doctor (same residence as yours) please write the family member’s or the cohabitant’s name, surname, date of birth and tax code, for the purposes of family reunification.

Family member’s or cohabitant’s doctor (same residence as yours)

Doctor’s full name

Name and Surname

Tax code

Date of birth

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

APPLICATION TO CHOOSE OR CHANGE DOCTOR