REGISTRATION FOR THE COURSE Knee Master Course • Miraiclinic.pl

DYŻUR ORTOPEDYCZNY
PN.-PT. 8:00 - 20:00

REGISTRATION FOR THE COURSE

Knee Master Course

Registration form

To register, you need to submit a completed registration form and make the registration fee payment within 3 days of registration.

The registration fee should be sent to the provided bank account number.

Santander Bank 58 1090 1883 0000 0001 4745 7470

Please send the confirmation of payment to the e-mail address provided

szkolenia@miraiclinic.pl

Registration will be processed on a first-come, first-saved basis, and the number of available spots is limited.

The registration deadline is 17th November 2023

Participant information

Full name *

Academic title

Professional license number

Phone number *

E-mail address *

Accommodation

Zakwaterowanie

There is an option for accommodation at the Nowy Gurewicz hotel, located within the clinic premises. Additional charges apply as per the price list on the: Apartamenty Otwock | Nowy Gurewicz

Please contact us to make a hotel reservation

+48 577 778 896

pokoje@nowygurewicz.pl

Without accommodationWith accommodation

Adress

Adress

City

Postal code

Country

Institution

Institution *

Clinic/Department *

Street *

Postal Code *

Invoice details

IMPORTANT: Please provide accurate information for the invoice.

Registrant
IndividualCompany

Company name/full name *

Street *

City *

Postal code *

Tax Identification Number (NIP)

Country *

Order summary

Total amount

Additional information

I agree to receive commercial information regarding productes and services offered by MIRAI Clinic sp. z o.o., Armii Krajowej 8, 05-400 Otwock, via the provided e-mail address and phone number, in accordance with the Act of 18th July 2002 on the provision of electronic services.

I hereby give consent for my personal data to be processed by MIRAI Clinic Sp. z o.o., Armii Krajowej 8, 05-400 Otwock, for the purpose of participating in Master Knee Course.

I have read and accept the Polityką prywatności regarding the processing of personal data.

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I will read it later I have read

PATIENT INFORMATION CLAUSE

In fulfilment of the information obligation in Article 13(1) of the General Data Protection Regulation (GDPR), we inform you that:

The Controller of your personal data are:
- MIRAI Clinic Spółka z Ograniczoną Odpowiedzialnością with its registered office in Otwock (05-400) at ul. Armii Krajowej 8, entered in the Register of Entrepreneurs of the National Court Register under number 0000796790, with tax identification number NIP 5322084436; (hereinafter referred to as "MIRAI Clinic" or "Controller");
Regarding the processing of personal data, you may contact the designated Data Protection Officer via e-mail iod@odosc.pl ;
Your personal data are provided directly at the time of your request - either in person or via the hotline. In the case of continuation of treatment started elsewhere, your data may also be obtained by the Administrator from other medical facilities. In special situations justified by your medical condition, your personal data may also be obtained from your relatives.
Your data will be processed as follows:
- for the purpose of providing health services, also remotely (so-called telemedicine), including the purpose of keeping medical records on the basis of the provisions of the Act on Health Care Activities, the Act on Patients' Rights and Patients' Rights Ombudsman, as well as the Act on Physician and Dentist Professions (Article 6(1)(c) and Article 9(2)(h) of the GDPR,
- where the purpose stems from the legitimate interests pursued by the Controller or by a third party, on the basis of Article 6(1)(f) of the GDPR, consisting of the assertion and defence of claims;
- where the purpose is based on the consent given pursuant to Article 6(1) (a) of the GDPR.
With regard to identification information related to provision of health services, the provision of data is mandatory and necessary for the provision of the service. Failure to provide them may prevent the provision of the service;
Recipients of personal data may be entities cooperating with MIRAI Clinic and the data may be transferred to entities processing personal data on behalf of the Controller, whereby such entities process data on the basis of an agreement with the Controller and only in accordance with their instructions;
Your personal data shall be stored:
You have the right to demand access to your personal data, as well as to rectify them (amend). You also have the right to demand erasure or restriction of processing, as well as to object to processing, but only if further processing is not necessary for fulfilment of a legal obligation by the Controller and there are no other overriding legal grounds for processing;
You have the right to lodge a complaint against the processing of your data by the Controller to the President of the PDPO (uodo.gov.pl);
Your data may be disclosed to a third country for the purpose of transferring medical records or/and continuation of treatment.
The Controller do not make decisions by automated means.