PLEASE COMPLETE THE FORM IN LEGIBLE BLOCK LETTERS
Global Philippine Healing, z. s. (registered association),
registered in the section and the title deed 27376 of the federal register, maintained by the Regional Court in Brno, IČ: 09722319, the registered office at Sinkulova 481/ 43, Praha 4 – Podolí. 14700, e-mail: firstname.lastname@example.org, phone number: + 420 732 199 084, Internet address: https://filipinskylecitel.eu/.
Confirmation of acceptance of general terms and conditions, consent to health care and processing of personal data and confirmation of mutual agreement of parents
I, __________________________________________, born on ________________________________,
residence _____________________________________________, telephone no.: _____________________,
e-mail: _______________________________________________________________, as a treated and fully independent person,* I grant the above-mentioned person, Global Philippine Healing, z. s., (hereinafter referred to as the “provider”), the following consents and confirmations:
1. I confirm that I have previously familiarized myself with the general terms and conditions as published here: https://filipinskylecitel.eu/ and have accepted them.
2. I confirm that the provider clearly explained to me in advance the intended health care in the way of traditional Filipino spiritual healing or traditional Filipino massages or consultations of an individual spiritual-healing procedure with a spiritual guide as it appears from the information to consumers here: https://filipinskylecitel.eu/ and from the general terms and conditions here: https://filipinskylecitel.eu/.
3. I confirm that I have previously familiarized myself with the information on the processing of personal data, as published here: https://filipinskylecitel.eu/, and I agree to its processing.
4. In the case of non-ordinary intervention on a minor child, as his legal representative, I confirm that the parents are in mutual agreement on this matter. I also confirm that in the case of a minor who is competent to judge, he was also given an explanation of the nature of the procedure.
5. If I am a woman, I declare on my honor that I am not pregnant nor am I aware that I might be pregnant.
6. I agree to the healing acts of health care according to the way of Filipino spiritual healing including the possible auxiliary acts of the assistant healer in case they are provided.
7. In the case of ordering health care massages, I agree to a traditional Filipino massage.
8. In case of ordering a consultation of an individual spiritual-healing procedure with a spiritual guide, I agree to this health care.
9. I am aware that I can revoke any of my consent at any time without giving a reason by notifying the entrepreneur of the revocation. Withdrawal of consent can be done in any way. In such a case, I withdrew from the health care contract with the provider or from the part of the contract to which the consent relates.
In ___________________ Day _____________________ Signature: ________________________________
* If the person being treated is a minor child, provide details about him and the details of the legal representative acting on their behalf. In particular mark the completion of the age of 14 years and 15 years. If there is not enough space, please use the other side of this form.