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Consent Form for Medical Consultation
Fertility Technology Center ("Clinic")

The Fertility Technology Center ("Clinic") will protect the personal data of the service user (“You”) in accordance with the Personal Data Protection Act B.E. 2562 (2019). Under the measures we have implemented for your benefit, rights, and privacy, the hospital requests your consent to process personal data as follows:

Personal data collected under the new patient registration service

The types of personal data the hospital collects from you depend on the circumstances of collection and the type of services you request. The personal data collected directly from you or from third parties includes:
- Identification data such as name, photograph, gender, date of birth, passport, ID card number, or other identification numbers.
- Contact information such as address, telephone number, and email.
- Service information such as doctor appointment details, personal data of relatives, requirements regarding room, food, and other additional services.
- Health information, reports concerning physical and mental health, your healthcare, laboratory test results, and diagnoses.
- Information related to your medication use and drug allergies.

Purpose of collecting personal data

The processing of personal data under the medical consultation service is for the following purposes:

- To provide medical consultation for your benefit and to complete the services according to the objectives of the visit or the service contract with the hospital. Activities under these objectives cover:
Preparation of treatment plans, provision of services, or delivery of hospital services.
Planning doctor appointments or receiving prompt assistance from the hospital.
Coordination and transfer of information to expedite the treatment plan.
Identity verification of patients, relatives, parents, curators, or guardians.
Requesting letters of guarantee for expenses from embassies or insurance companies.
Other activities essential to health and public health services.
- Other purposes that support the above objectives or for which your consent is obtained from time to time.

Disclosure of Personal Data

The hospital will not allocate, disclose, and/or transfer the data and personal data of service users or caregivers to any legal entity or person, both in Thailand and abroad, for independent use, unless you or the caregiver have requested and authorized the hospital to disclose it to a legal entity or third party, or you have given consent to the hospital for such disclosure, and/or you have given consent to a third party and are aware of such personal data delivery, or the disclosure is to fulfill a contract for your benefit, or is in compliance with the law by the hospital.

Retention periods and Security of personal data

The hospital recognizes the importance of maintaining the security of your personal data. Therefore, the hospital has established appropriate security measures consistent with personal data confidentiality to prevent loss, unauthorized or unlawful access, destruction, use, modification, or disclosure, in accordance with the hospital's Information Technology Security Policy and Guidelines.

Your personal data will be stored for a period of 10 years or until a request to exercise your rights is submitted, subject to the hospital's regulations and consideration procedures.

Rights of personal data owner

Within the scope of new patient registration, the hospital wishes to inform you of your legal rights regarding your personal data. The hospital reserves the right to consider your request in accordance with hospital regulations, the law, and the appropriate impact on the rights and freedoms of others. The hospital will notify you of the result of your request within 15 working days via the contact information you provided to the hospital or in the application.

Inquiries about personal data protection rights

You may inquire and exercise your rights via email at [email protected], by telephone at 02-734-0000, or by contacting the hospital directly. You can study the hospital's Privacy Policy at www.vejthani.com

Consent to the processing of personal data for marketing purposes

You consent to the hospital processing your personal data for participation in marketing activities, covering the provision of marketing information, offering products and services, answering questions, responding to complaints, providing convenience, presenting benefit programs, public relations, customer relations, customer satisfaction surveys, market research, statistical analysis, processing, and display of information to improve products and services or create new products and services for the greater benefit of hospital service users.

I acknowledge that personal data protection standards in Thailand and other countries may differ. I have read, acknowledged, and given consent to the hospital to process my personal data for all the above purposes, and confirm that I am free to decide to give consent without affecting my rights to receive healthcare services from the hospital in the future.