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Form of address *: Mrs. Mr.
First name:
Please inform us
how we can reach you*:
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I agree with the Data Usage Note

Data Usage Note

Your personal information will be treated confidentially and will be used exclusively to contact you by e-mail, telephone and/or in writing.

Your information will be appropriately protected against access by third parties, as well as collected, processed and used in accordance with the provisions of the Federal Data Protection Act. The provision of your personal data, in particular your health data, is voluntary.

If required, your request will be forwarded to the responsible authorities or persons within the Hospital of the University of Munich (KUM). In this context, there is a possibility that non-medical staff of the hospital may be aware of the information you have disclosed. A transfer or transmission of this information to third parties outside of the hospital will not take place. Your data will be deleted at the latest 3 months after evaluation or forwarding of your information to the responsible body.

You may revoke your authorization for the purposeful processing and use of the data in written form at any time without providing any reasons. Your stored data will be deleted immediately within the scope of legal regulations.

The relevant information about your request will be sent to the specified e-mail address without information from health data unencrypted or forwarded. This constitutes a data protection risk.

"I am aware and I am informed that my personal data on the Internet can be disclosed to third parties and, if necessary, unprotected for everyone to see!"

Requested patient and personal application documents will only be sent to us by mail, to a reasonable extent, if you have provided your postal address.

Fields marked with an asterix * are obligatory.