MIH Consent Form

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Consent Subject Signature/Name *

Consent Contact Purpose *

More information on cervical cancer

Notification should more self-test kits be available

Notification when vaccinations are available

Future events from us or our sponsors

Decline to give any consent for contacting me

Consent Permission *

I am giving permission to MIH and its affiliates to use collected information for analysis purposes in an anonymous manner

I understand that appropriate safety measures have been put in place by MIH to protect the privacy and security of my information.

I am made aware that I can cancel my consent at any time without giving reason or without disadvantage to any services.

Decline to all consents listed above

Encounter Location:*

Provider Name:

Provider's system-id:*

Encounter Date *