Delete my documents

Personal data

First name, surname*

Gender*

SelectFemaleMaleOther

Date of birth*

Address*

Postcode and city*

Patient number

Telephone number*

E-mail*

Reason for the cancellation

Request for cancellation

I hereby request the destruction of my entire medical file. I am aware that this process cannot be cancelled.

Check contact information

Insert a scan of a valid driving licence, identity card or passport of the patient here. Add attachment max. 1MB

Data protection notice

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.