Registration | Leading English-speaking Clinic in Budapest

Medical Information Release Consent Form

1. Medical Information Release Consent Form

I hereby acknowledge that FirstMed-FMC Kft. may hand over medical documentation related to me to the person and/or in the manner I have designated in this declaration. The medical documentation shall be deemed as handed over to me – in case of personal delivery, by the delivery, in case of an e-mail, by the sending, and in case of registered mail, by the sending. Therefore, as long as my instructions as stated herein are followed, I may not raise any claims against FirstMed-FMC Kft. regarding the handing over of my medical documentation, and I may not claim that FirstMed-FMC Kft. has breached my privacy rights with regard to the disclosure of my medical documentation.

Please check all that apply, then fill in the relevant parts of the form.*
- I DO NOT CONSENT to having my medical records sent by any means. I will always pick them up personally.
- I consent to receiving my medical information at the below e-mail address
- I consent to receiving my medical information at the below mailing address by registered mail
- I consent to having my medical records sent to the below Insurance Company
- I authorize the following person to receive my records on my behalf personally
- I authorize the following person to receive my records on my behalf by email
My name*
First Last
My email address*
Enter Email Confirm Email
My postal address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Name of insurance company
Name of authorized person
First Last
Status of authorized person (friend, family...etc.)
Email of authorized person
Enter Email Confirm Email
Phone of authorized person
Address of authorized person
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please do not write in ‘ALL CAPS’, use Proper Case [e.g. Smith, John]

1. Registration Form

Personal Information

State required identification

Medical insurance

Medical insurance

Address

Emergency Contact

Results (Laboratory / Radiology)

*You should get an email after your registration. FirstMed will never share your Email address or any personal information with a third party.

1. Medical Information Release Consent Form

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