Clanwilliam Health - Right to be forgotten request form

Before completing this form please ensure that by making this request you will not infringe on any of your medical or legal obligations.

Account No. GP/Pharmacy Name Email address Contact Number Patient Name Patient Address

Patient Date of Birth

Authorisation Declaration

I represent that the information in this request is accurate and that I am authorised to submit this request.

Understanding

I understand that Clanwilliam Health will not be able to process my request if the form is not properly filled out or if the request is incomplete.

Signature

Fill in your details below to receive a free consultation or follow-up!

By typing your full name above, you are providing us with your digital signature, which is as legally binding as your physical signature.

By filling in this form you are agreeing to be contacted by a member of the Support Team in order to progress this request.

Thank You!