This informed consent (the “Consent”) is made by a healthcare professional identified below (the “Professional”). ExCEEd Orphan s.r.o. (ID No. 07407696) is a limited liability company with registered seat at U Habrovky 247/11, Prague 4 – Krč, 140 00 Prague, Czech Republic and registered with the Commercial Register at the Municipal Court in Prague, section C, file 300530 (the “ExCEEd Orphan”). ExCEEd Orphan as a data controller maintains a database of healthcare professionals in compliance with all applicable laws and regulations relating to the collection and processing of personal data including the European Regulation 2016/679 (General Data Protection Regulation – “GDPR“). All the personal data filled in this form will be stored, continually updated and further processed together with other data (such as professional credentials, experiences, skills and preferences etc.) published or provided to ExCEEd Orphan by the Professional.




Name and Surname:


Specialization: ___________________________________________________________________


E-mail address (work):




Telephone number (work):




Professional confirms that his/her personal data will be registered in database maintained by ExCEEd Orphan and further processed based on his/her Consent under the Article 6(b) GDPR. The purpose of the processing is to provide Professional with up to date information about various scientific projects/activities and to manage potential third parties’ relations with Professional.


Personal data to be processed by ExCEEd Orphan until the Professional withdraw his/her Consent. ExCEEd Orphan will periodically review its databases to make sure that the information therein is up-to-date and delete obsolete data.


Personal data will not be transferred to the third parties, except (a) to service providers acting under instructions of ExCEEd Orphan or (b) to governmental authorities when required by the applicable laws, (c) to the business partners listed at ExCEEd Orphan website (


Professional has the right to access, rectify and ask for the erasure of his/her personal data, to object to the processing of the data and to withdraw Consent anytime by contacting ExCEEd Orphan at the following email address: Professional has also the right to lodge a complaint with a relevant data protection supervisory authority.


Professional hereby grants his/her consent to the processing of his/her personal data by ExCEEd Orphan for the purpose and in accordance with the conditions under this Consent.



Date: __________________                       



Signature: __________________________________




To obtain the CONSENT FORM in a different language refer to:

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