MY HEALTH

e-form

ACCESS BY DOCTOR TO YOUR PERSONAL
HEALTH DATA THROUGH THE MYHEALTH SERVICE

You can give a doctor access to your personal health data through the myHealth service by using the online service or by completing and signing this form and sending it to the myHealth office. DOCTOR'S DETAILS (Doctor's full name) Medical Registration Number Telephone/mobile numbers YOUR First Name YOUR Surname YOUR Date of birth Identity Card Number Telephone/mobile numbers Your E-Mail Address I, the undersigned, give my consent for the above-named doctor to access my personal health data through the myHealth service. I understand that I can request revocation of this consent by writing to the myHealth office by post or by email.

Date

Your signature

Doctor's signature (as witness)

Kindly note: Signatures can be applied via touch screen or mouse