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The undersigned

Applicant’s surname

Applicant’s name

Applicant’s date of birth

Applicant’s place of birth

Applicant’s tax code

Applicant’s residence (Enter full address)

City / Competent District

Applicant’s E-mail

Applicant’s telephone number

Applicant’s Identity Document

Any other attachment

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

Under-18 relatives’ data

General Practitioner’s data:

Dr.

Registered in the GP list of the following city:

City where the GP’s office is located

Doctor’s consent attached

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

Select

Doctor’s consent, if You have it:

Otherwise, the Health District Registry Office will check if the doctor You have chosen can accept You as his/her patient, which can happen only in the following circumstances:

To pursue a trustful relationship
For reasons of proximity or better viability than the previous GP’s office
Serious and objective circumstances hindering health care delivery (specify)
Serious and specific illnesses

as long as the doctor has not exceeded his/her maximum number of patients.

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

CHOOSING THE GENERAL PRACTITIONER BY DEROGATING RESIDENCE