To request the deletion of your medical records, please complete the following form:
First name, surname*
Gender*
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Date of birth*
Address*
Postcode and city*
Patient number
Telephone number*
E-mail*
Reason for the cancellation
I hereby request the destruction of my entire medical file. I am aware that this process cannot be cancelled.
Insert a scan of a valid driving licence, identity card or passport of the patient here. Add attachment max. 1MB
I consent to my data being processed and stored for the purpose of contacting me. The Data protection notice I was able to take note of this. Consent can be revoked at any time with effect for the future. To do so, please simply send a short e-mail to info@acuramedischcentrum.nl send. Please read the Data protection notice for further information.
The fields marked with * are mandatory.
