MIH Consent Form
Demographics
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Consent Details
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:
*
Encounter Location
*
...
Provider Name:
*
Provider's system-id:
*
Encounter Date
*