Patient consent (template)

This template covers consent for sensitive personal data; it does not replace the informed consent for each procedure. Replace the text between « », review it with your lawyer and send it for signature from ISSA Salud. The clinic is responsible for its content and validity.

I, «patient name», give my express consent for «clinic name» to process my sensitive health data for my care, the building of my clinical record and the follow-up of my treatments, under its privacy notice, which I have read.

I agree to receive reminders, confirmations and follow-ups by «WhatsApp, Messenger, Instagram, email or phone», and I understand that a virtual assistant with artificial intelligence, supervised by the clinic’s team, may serve me without giving diagnoses or medical instructions.

Tick only what you authorize:

• Photos for my clinical record and the follow-up of my treatment.
• Academic or professional use without my being identifiable.
• Use in the clinic’s advertising or social media, which I can withdraw at any time.

I can withdraw this consent at any time by writing to «email», without retroactive effect and knowing the clinic must keep the record for as long as the law requires.

Full name, date, place and handwritten or electronic signature of the patient or their legal representative. ISSA records the date, the IP address and the verification code of the electronic signature.

For each procedure, NOM-004-SSA3-2012 requires an informed consent letter with at least:

• Name of the institution and establishment, document title, place and date.
• The authorized act, with its expected risks and benefits.
• Authorization to handle contingencies and emergencies arising from the act.
• Full name and signature of the patient or their representative, of the physician performing it and of two witnesses.