Web Quality

The undersigned:

Applicant’s surname

Applicant’s name

Applicant’s residence (Enter full address)

City of residence

Applicant’s tax code

Applicant’s E-mail

Applicant’s telephone number

Applicant’s Identity Document

Any other attachment

ASKS

for his/her son/daughter:

Children’s data

to keep the following Pediatrician

Pediatrician

which is allowed only in case of:

Severe, chronic and persistent illness
Psycho-physical immaturity
Psycho-social conditions causing risks or severe physical problems
Brothers or sisters in charge of the same pediatrician

Doctor’s consent attached

Request for the Health District to verify the pediatrician's consent

Select

Pediatrician’s consent, if You have it:

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 keep the Pediatrician for over-14s