This is a sample of informed consent that you will be requested to sign upon your visit to our center.
CONSENT FORM
COGNITIVE ASSESSMENT AND REHABILITATION
I, the undersigned, give my consent for my next of kin named_________________ ___________________________ to undergo cognitive function assessment and rehabilitation at MAT Noesis Cognitive Center & Tech Solutions Ltd. I understand that the purpose of the evaluation is to assess my/ my next of kin’s cognitive functioning, and to provide individualised cognitive rehabilitation.
I acknowledge that MAT Noesis Cognitive Center & Tech Solutions Ltd collects and stores personal information, including but not limited to, name, gender, date of birth, place of residence, address, occupational status, medical, developmental, social and pharmaceutical history, interests, preferences, and data collected during the evaluation and/or rehabilitation of me/ next of kin.
Form data is stored securely in lockers, accessible only by authorized team members. Electronic data is stored in an online Cloud service, with strict security measures. I understand that my/ my next of kin’s personal data will not be used for any purpose other than the purposes set out in this document.
Furthermore, I am aware that this personal data may be used in a fully anonymised form for research activities, including research articles and publications. By providing this consent, I acknowledge that my contribution will contribute to research into the diagnosis and treatment of cognitive decline. I understand that my/ my next of kins’ personal data will not be used for any purpose other than the purposes stated in this document.
Finally, I understand that I have the right to request in writing, and obtain within 20 working days, at any time and without justification, access, processing and/or deletion of my/ my next of kins’ data. I am aware that, anonymously for data previously included in published material with my consent, may have already been reproduced or copied by other persons, without the possibility of control of these by our center and without any liability on our part.
In case I have concerns or complaints related to the handling of my data, I can contact Mr. Filio Savvidis at fsavvides@cytanet.com.cy.
I have read and understood the information provided in this form. I have had the opportunity to raise questions/concerns which have been addressed to my satisfaction. I freely and voluntarily consent to the collection, storage and use of my personal data as described in this document.
Name: __________________________________________
Signature: __________________________ Date: ___________
[If applicable]
Name of next of kin: _________________________________________
Signature of next of kin: _______________________
Date: ___________
