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Amber Surgery LTD

  +353 87 669 1441

  info@ambersurgery.com

  Unit 12, Burnell Square, Mayne River St, Malahide Rd, Northern Cross, Dublin 17, D17YW40, Ireland

  Tue - Sat: 10:00 am - 7:00 pm
Sun: 11:00 am - 7:00 pm, Mon: closed

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Contact form




    Information Sharing Consent Form

    I hereby consent to Amber Surgery Ltd. collecting, using, processing, transferring and sharing my personal information (including my medical, images, mental health records if applicable) with any healthcare professionals, clinics, supporting doctors, medical team, staff and/or individuals, so that my suitability for a medical/surgical procedure, and any aftercare required, can be assessed and a care plan put in place. I agree to my information being shared in order to help in the assessment and/or provision of any medical/surgical care. I understand that Amber Surgery Ltd. may be required to hold information gathered about me and as such my rights under the Data Protection Act will not be affected.

     

    Statement of Consent:

    • I understand that personal information is held about me.

    • I have had the opportunity to discuss the implications of sharing or not sharing information about me.

    • I agree that personal information about me may be shared with:

      • HSE and any other private or public Health Services both in Ireland and abroad, including my GP practice.

      • Third parties engaged in the assessment and/or provision of medical/surgical care to me

    • I understand the purpose for disclosing and sharing this personal information to the parties noted above.

    Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time. Should you have any questions about this process, or wish to withdraw your consent please contact: Amber Surgery Ltd through the email info@ambersurgery.com