Application to keep the Pediatrician for over-14s
The undersigned:
Applicant’s surname
Applicant’s name
Applicant’s residence (Enter full address)
Select an option
30010 - Campagna Lupia
30010 - Campolongo Maggiore
30010 - Camponogara
30014 - Cavarzere
30015 - Chioggia
30010 - Cona
30031 - Dolo
30032 - Fiesso dArtico
30030 - Fossò
30020 - Marcon
30030 - Martellago
30034 - Mira
30035 - Mirano
30033 - Noale
30030 - Pianiga
30020 - Quarto dAltino
30030 - Salzano
30036 - Santa Maria di Sala
30037 - Scorzè
30038 - Spinea
30039 - Stra
30121 - Venezia
30122 - Venezia
30123 - Venezia
30124 - Venezia
30125 - Venezia
30126 - Lido e Pellestrina
30132 - Venezia
30133 - Venezia
30135 - Venezia
30141 - Murano
30142 - Burano
30171 - Mestre Venezia
30172 - Mestre Venezia
30173 - Favaro Venezia
30174 - Chirignago Cipressina Trivignano Zelarino
30174 - Carpenedo Terraglio
30175 - Marghera Venezia
30176 - Marghera Venezia
30030 - Vigonovo
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
Name and surname
Date of Birth
Tax code
to keep the following Pediatrician
Pediatrician
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
Which is allowed only in case of:
Attach doctor's acceptance/availability document
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
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