Patient Device Concern Form

Patient Device Concern Form

This form is designed to ensure transparency and compliance with data protection regulations.
Patient Name*

First NameLast Name
Clinic*
Date of Hooked-up*

MonthDayYear
Date
Gender*

MaleFemale
Contact Number*
Email*
example@example.com
Concerned Device
Device*

24-Hour ABPM24-Hour HolterAnkle Brachial IndexSpirometer
Please give us more details about your concern*
Upload photo of the device/s*

Cancelof
Confidentiality
I understand that the information provided will be used solely for the purpose mentioned above and will not be shared with any third parties without my explicit consent, unless required by law.

I acknowledge that providing this information is voluntary and that I have the right to refuse or withdraw my consent at any time without affecting my rights.

I also understand that I may request access to the information collected about me and request corrections if necessary.
Should be Empty:

Concerned Device