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Privacy Consent Form
FOR USE WHEN COLLECTING PERSONAL DATA IN/FROM EUROPEAN UNION
Required by European Union General Data Protection Regulation 2016/679 (“EUGDPR”)
To Be Signed by Individual Providing Personal Data
Health Queries is the controller of your personal data. You may contact Health Queries at 4083 Phase 2 Urban Estate Dugri Ludhiana Punjab India or by phone and email at: +918427233150 and email@example.com.
Your personal data will be used for the following purposes (check all that apply):
___ Technical support;
___ Other [include detailed description of use of personal data].
The categories of personal data you are being asked to consent to Health Queries’s collection and use are your name, address, email address, telephone number and [include description of any other personal data collected].
Health Queries will share your personal data with third party software providers who collect, store and process your personal data on behalf of Health Queries and who are contractually obligated to keep your personal data confidential subject to appropriate safeguards to prevent it from unauthorized disclosure. Health Queries also intends to share your personal data with: [identify all company units and third parties that will receive personal data].
Your personal data will be transferred out of the European Union to Health Queries located in the United States.
Your personal data will be stored in accordance with the record retention requirements applicable to Health Queries as a private organization of , and any other applicable U.S. laws. Under the EUGDPR, you have the right to request access to, rectify, erase and restrict the processing of your personal data. You also have the right to revoke this consent to use your personal data. If you feel Health Queries has violated the EUGDPR, you have the right to file a complaint with the appropriate EU supervisory authority. These rights are more specifically described in the Privacy Notices posted on Health Queries’s website at http://www.Health Queries.in.
Please [sign/electronically sign/check box below], date and return by [email/submit] the below:
I consent to Health Queries using my personal data for the purposes described in this notice and understand that I can withdraw my consent at any time.
___ gives consent ___ does not give consent
Name of Individual providing Consent: _______________________________________________________
Address of Individual providing Consent: ______________________________________________________
Date of Signature:______________________________________________________________