Policlinico Universitario Campus Bio-Medico

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To cancel an appointment for an outpatient visit or diagnostic service

Please complete all fields. After you have submitted this form, an operator will cancel your appointment. You will not be contacted again about this matter.

Appointment/diagnostic service to be cancelled


Date of booked appointment:
Time ok booked appointment:

Scheme selected by booking of appointment/diagnostic service

Medico richiesto:		(dato facoltativo)
Numero impegnativa:		Guarda un esempio
Data impegnativa:

Applicant's personal data

Family name:	Given name:
Place of birth:	Date of birth (dd/mm/yyyy):

Within the meaning of Article 13 of Legislative Decree No. 196 of 30 June 2003 on the processing of personal data, we would advise you as follows: 1.Your personal data will be processed by the Campus Bio-Medico University Hospital and entered into a database so it can be processed in connection with your request that an appointment be arranged for you for medical services. 2.The data is processed by computer. Proper security measures will be taken to ensure your data is kept secure and confidential and to minimise the risk of loss, illicit use or improper or unauthorised access to same. 3.The provision of some of your personal data is optional. We would advise you, however, that with the exception of those fields shown as being optional, all other fields must be completed to enable us to respond to your request in the most appropriate manner. Unless you provide us with this data, the Campus Bio-Medico University Hospital, Rome, will unfortunately be unable to give your request any further consideration. 4.Your personal data will only be disclosed to persons within the university hospital who need to have sight of it as a result of their professional duties or their role within the hospital. 5.The data controller is the Campus Bio-Medico University Hospital, the head office of which is at 200, Via Alvaro del Portillo, 00128 Rome, Italy. With regards your personal data, please note you are able to exercise your rights under the terms of Article 7 of the Code governing the protection of personal data which, inter alia, entitles you, under appropriate circumstances, to ask for your data to be corrected, updated, amended or supplemented. All such requests should be sent in writing to the Campus Bio-Medico University Hospital, 200 Via Alvaro del Portillo, 00128 Rome, Italy.
I accept the terms set out in this form. Within the meaning of Legislative Decree no. 196/2003, I hereby confirm that I have read the information set out above and agree to my personal data being used for the purposes and within the limitations defined therein.

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