Secure Start Consent Form - Interaction with you

Protecting your personal data is important to us at Hollister Ltd & Dansac Ltd, Rectory Court, 42 Broad Street, Wokingham, RG40 1AB, subsiduaries of Hollister Incorporated ("Hollister"). Hollister & Dansac are transparent about how we use your personal data and gives you the right to choose how much personal data you want to share with us by selecting the level of service you want.

What is GDPR?

The General Data Protection Regulation (GDPR) is a European Privacy law that came in to effect in May 2018. As the economy becomes increasingly more digital and as information multiplies, ensuring data privacy and security is becoming highly important. GDPR specifies how your personal data should be used and protected by the companies who obtain your information. Companies that are handling health-related information such as Hollister Ltd are in full scope of GDPR and must be more transparent with their customers and patients' sensitive data.

The definition of 'personal data' in GDPR is more detailed than previous data protection law. As well as applying to things that obviously identify an individual, such as name, address and date of birth, information such as a computer's IP address or genetic sequence data can also be considered personal data. These definitions reflect changes in technology, the capacity to link data to identify individuals and the way organisations collect and store information about people.

Your rights and knowing how your data is used

GDPR strengthens your rights over your personal data. There are exceptions, but broadly, you will have greater rights to be provided with information about what data about you is being processed, by whom, why and how. It will also be easier to object to your personal data being used where you have a right to do so.

Please tick what level of service you would like to receive from Hollister Ltd & Dansac Ltd from the options below:

I want to receive samples and related product guide;

I consent to the processing of my name, address, contact information (such as: telephone number and e-mail address) and medical information, which consists of data related to my health and is necessary to identify the correct product (such as: mobility, type of surgery, length of product usage, skin conditions) for this purpose.

I want to stay informed about your products and services which may be of interest to me via email, postal mail, telephone, SMS, etc.;

I consent to the processing of my name, address, contact information (such as telephone number and e-mail address), gender, and medical information, which consists of data related to my health and useful to identify my direct marketing needs (such as: mobility, type of surgery, length of product usage, skin conditions) for this purpose.

I want to participate in feedback programmes, such as surveys, product or service evaluations, and/or clinical trial activities;

I consent to the processing of my name, address, contact information (such as: telephone number and e-mail address), age/birthday, gender, and medical information, which consists of data related to my health and necessary to ensure the suitability of my participation (such as: mobility, type of surgery, product usage, skin conditions, lifestyle) for this purpose.

I want to be a member of Dansac's customer care programmes; (e.g. Secure Start)

I consent to the processing of my name, address, contact information (such as: telephone number and e-mail address), age, gender, religion, information about my caregiver, and medical information, which consists of data related to my health necessary to provide me with the correct support (such as: medications, mobility, type of surgery, length of product usage, skin conditions)

Please complete and sign the consent form overleaf.

You have the right to withdraw your consent at any time by contacting data.officer@hollister.com

Such withdrawal only has future effect (i.e. the withdrawal of your consent has no effect on the lawfulness of the data processing and disclosures before the withdrawal was made).

Please find further details regarding the processing of your personal data on the "Your Data" page of our website www.hollister.co.uk or call us on Freephone 0800 521 377

Together with

Secure Start Consent Form

Title

First Name

Surname

Address

Postcode

Telephone No.

Date of Birth

Date of Surgery

Discharge Date

Stoma Type

Colostomy

Ileostomy

Urostomy

Is Emergency?

Is Permanent?

Hospital

Stoma Nurse Name

Products

One-Piece

Two-Piece

Flat

Convex

Soft Convex

Name of Current Pouch

Manufacturer

Product Code

Any other products given (please state products)

Delivery Service (if known)

Date of SCN home visit

Any other relevant information

Signature

Date

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