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Declaration of consent regarding data protection

Dear patient,

We require your consent for the processing of your data and services for our treating physicians, the billing of services rendered and for the processing of your data for research purposes. You explain I hereby expressly consent to the following:

1. Disclosure of all data related to your treatment, in particular name, address, date of birth, treatment data, Treatment courses for the purpose of billing and assertion to LGP Lebenswert Gesundheit und Prävention GmbH, Hauptstraße 202-204, 51465 Bergisch Gladbach or a subsidiary.
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2. Assignment of the claims resulting from the treatment to LGP Lebenswert Gesundheit und Prävention GmbH.
3. Passing on all personal data collected in connection with this master data collection for the initial presentation to the attending physician.

I hereby give my consent for data processing and signup: