The undersigned *

DOB *

(dd/mm/yyyy) *

Resident in*

Address *

E-mail*

DECLARES

that they wear an ocular prosthesis applied by Dalpasso s.r.l. with registered office in Reggio Emilia, via Turri n. 10 *

YESNO

that they are aware of the legal consequences of providing false data or information *

YESNO

that they have been informed by Dalpasso s.r.l. regarding the standards that govern the processing of sensitive data pursuant to Legislative Decree 196/2003 *

YESNO

holding harmless Dalpasso s.r.l. from all responsibility in relation to this request*

YESNO

REQUESTS

a copy of the photographic digital images taken and stored in the magnetic archives of the company Dalpasso s.r.l. to be sent to them.

date on which photographs were taken *

For that purpose chooses the following support for the requested images:
CD Rom to be sent by post with costs charged to the addressee *

Email to be sent to the following address: *

I will provide a photocopy of a form of identification as soon as possible via: *

FaxE-mailServizio postale

PRIVACY

The undersigned acknowledges the information notice provided pursuant to Art. 13 of Legislative Decree 196/2003 and provides consent for their personal data to be processed for the aims indicated and to be subject to communication to the parties and for the purposes stated.
I ACCEPT