Following confirmation of your appointment, please complete and return this information sheet BEFORE your appointment. 

This medical information sheet is strictly necessary for the creation of your medical file, the establishment of a diagnosis and your effective care by Dr C. DIERICKX.

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Furthermore, Dr C. DIERICKX, in its capacity as data controller, within the meaning of European Regulation(EU) 2016/679 of the European Parliament and of the Council of April 27, 2016, on the protection of individuals with regard to the processing of personal data and on the free movement of such data (hereinafter the "RGPD"), implements all reasonable organizational and security measures regarding, among other things, the collection , management as well as storage of your data that could be used for a purpose other than diagnosis and to medical care, namely, primarily for the purposes of scientific study or publication of articles in professional scientific journals. 

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Before sending this form, please consult the confidentiality policy set up by Dr C. Dierickx: Privacy Policy

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By completing and sending this information sheet, you also mark your consent to the processing of your personal data within the meaning of the RGPD for the purpose(s) listed under the privacy policy.

Don't forget to let us know if any of your contact details change!