Registration form

Patient

Name

Last name

Last name 2

Phone number

E-mail

Confirm email

Birth date

Gender

Marital status

ID/Passport

Profession

Nationality

Postal code

Address

City

Province

(if you do not live in Spain, please select "extranjeras")

Country

Insurance

Policy number

According to the data protection law and regarding your personal data included in this form and in any other document provided to us concerning your patient condition, as well as any other data provided verbally or in writting throughout the treatment you perform, we inform you of the following:

Mark with X as appropriate to the type of authorisation

Sending information and/or documentation to Referral Doctor

Sending information and/or documentation to Intermediates

Sending general information about FutureLife Group brands and services.

Be part of the Rainbow Fertility Barcelona project and access the advantages it offers to the LGTBIQ+

Processing of my data for scientific, research and/or teaching purposes

Click here if you are undergoing the Assisted Reproduction treatment with a Partner

Partner

Name

Last name

Last name 2

Phone number

E-mail

Confirm email

Birth date

Gender

Marital status

ID/Passport

Profession

Nationality

Postal code

Address

City

Province

(if you do not live in Spain, please select "extranjeras")

Country

Insurance

Policy number

Mark with X as appropriate to the type of authorisation

Sending information and/or documentation to Referral Doctor

Sending information and/or documentation to Intermediates

Sending general information about FutureLife Group brands and services.

Be part of the Rainbow Fertility Barcelona project and access the advantages it offers to the LGTBIQ+

Processing of my data for scientific, research and/or teaching purposes

Co-responsible of the data processing:

For the purposes related to the provision of the service and medical assistance, the responsable of the data processing is INSTITUT MARQUÈS OBSTETRICIA I GINECOLOGIA, S.L. ("INSTITUT MARQUÈS”) NIF: B62187323, Address: Avda. Diagonal, 662-664, 08034 Barcelona. Telephone: 932858216, Email (DPO): lopd@institutomarques.com
For the purposes related to commercial communications, information about our services and quality surveys, the responsible of the data processing are, as co-responsibles, INSTITUT MARQUÈS and FUTURELIFE A.S., provided with NIF 04213190. Address: Na Poříčí 1047/26, Nové Město, 110 00 Prague 1, Czech Republic.

Purpose of the data processing:

Please find below the purposes for which we will process your personal data.

Management of your registration as a patient and related treatments. The information collected in this form will be added to our database with the purpose of registering you as a patient of Institut Marquès. Your personal data are necessary for the proper management of your patient file, billing processes, as well as the correct administrative and organisational management of our centre. The legal basis that legitimates the processing of your personal data is your consent as a patient and the execution of the contract.

Provision of medical services and monitoring of treatment. We will process your medical and health data for the proper provision of the requested medical services. This includes sending images and other documents generated with reference to your donation and/or treatment and forwarding them to the e-mail address you have provided to us. The legal basis for the processing of your personal data is the necessary performance of the contract.

Sending quality and satisfaction surveys. We will process your contact details in order to send quality and satisfaction surveys about our services and the care received. This information is necessary for us, as it allows us to adapt our activity and develop better products and services for our patients. The legal basis that enables us to process your personal data is the legitimate interest of FutureLife group. Your data for this purpose will be processed by Institut Marquès and FutureLife group as co-responsibles for the processing.

Sending commercial communications. Also, and provided that you have expressly requested it, we may process your contact details to send you information / newsletters of any of the brands belonging to the FutureLife group. Your data for this purpose will be processed by Institut Marquès and FutureLife group as co-responsibles for the processing.

To be part of the Rainbow Fertility Barcelona project. Provided that you have expressly requested it, we will process your data to register you in the Rainbow Fertility Barcelona project of INSTITUT MARQUÉS, becoming part of it for all communications and accessing the advantages it offers to the LGTBIQ+ group. The legal basis that legitimates the processing of your personal data is your consent. Your data for this purpose will be processed by Institut Marquès and FutureLife group as co-responsibles for the processing.

Processing of data for scientific, research and/or teaching purposes. When you have expressly gave your consent for it, we will process the personal data contained in your medical records for scientific, research and/or teaching purposes with the aim of better understanding reproductive health conditions, improving assisted reproduction treatments and training specialists in this field. The data used will be previously anonymised or coded to guarantee your privacy. This means that any information that could identify you will be removed or modified in such a way that it is not possible to associate the information with you. Your data for this purpose will be processed by Institut Marquès and FutureLife group as co-responsible for the processing.

The data will be processed solely for the above-mentionned purposes and may not be further processed for purposes incompatible with those described above. In the event of being used for purposes other than those explained above, you will be provided with all relevant information prior to the start of the new processing.

In the event of providing data of third parties other than the person responsible for completing this form, the person responsible for completing this form guarantees that he/she has informed the data subjects of the matters referred to herein relating to the processing of their personal data and, where necessary, has obtained their express consent.

Data retention period:

Your data may be retained for the duration of the service or medical treatment. Once the treatment has been completed, we will store your data for the legally established period, in order to deal with any type of complaint.

In the event that you have expressed your wish to receive advertising information/newsletters, we will keep your data until you exercise your right of objection and tell us otherwise, without affecting the lawfulness of the processing based on consent prior to withdrawal. We remind you that we have enabled a simple and free of charge system in each of our communications or newsletters, where you can exercise your right to object to the processing of your personal data for advertising purposes.

Recipients:

Terceros de referencia: Podremos compartir la información generada como paciente de Institut Marquès con aquellos terceros de referencia siempre que Usted nos autorice. Estos terceros pueden ser un médico de referencia u otro intermediario que usted haya designado expresamente.

Third party referals: We may share the information generated as a patient of Institut Marquès with those third party referals provided that you authorise us to do so. These third parties may be a referral doctor or other intermediary who you have expressly designated.

Insurance companies and mutual insurance companies: If you have an insurance contract, we may share your personal data with these entities in order to verify the coverage of the service, and to manage and process the payment of the healthcare expenses provided. The personal data shared will be limited to which is strictly necessary for these purposes, and under no circumstances will your medical data and information be communicated.

Institut Marquès does not carry out international data transfers.

Rights:

If you wish to exercise your rights of access, rectification, cancellation, opposition, deletion, restriction and portability, according to law, you can do so by contacting us in writting at INSTITUT MARQUES OBSTETRICIA I GINECOLOGIA, Avda. Diagonal, 662-664, 08034 Barcelona or by emailing lopd@institutomarques.com attaching a copy of your ID.