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The undersigned

Applicant’s surname

Applicant’s name

Applicant’s date of birth

Applicant’s place of birth

Applicant’s residence/domicile (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

According to the National Collective Agreement on Pediatrics, applies to choose by derogating residence, for his/herself and for his/her relatives:

Under-18 relatives’ data

Pediatrician’s data:

Dr.

Registered in the Pediatricians’ list of the city of:

Pediatrician’s city

Who has agreed to accept the applicant(s) as his/her patient(s) (see footnote).

To pursue a trustful relationship

For reasons of proximity and better viability than the previous GP’s office

Serious and objective circumstances hindering health care delivery (specify)

Serious and specific illnesses

Which can happen only in the following circumstances:

Attach doctor's acceptance/availability document

Please note: If you have chosen a pediatrician belonging to a different Health Authority, you need to upload the consent of the Health Authority the new pediatrician is enrolled in, as well.

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