Data Subject Rights Request Form

Please complete this form, if you wish to exercise your rights as a Data Subject.

Required field are marked ^*

User type
Request type
About you
Request details

I am a (an) ^*:

Patient

Employee

Vendor

Prospective employee

Others

Select request type^*:

Info request

Update data

Opt out

Object to processing

Data deletion

Review automated decision

File a complaint

First Name ^*

Last Name ^*

Email ^*

Mobile Number ^*

Country ^*

Request Details ^*

Unique ID (Please include ID like Emp ID, MRN etc)

Email ^*

By providing your email, you agree to allow Health City to communicate with you via email. We will not sell or share your personal information ^*. Please read our updated Privacy Policy

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Data Subject Rights Request Form

User type

Request type

About you

Request details

Inquiry Submitted