Form for adults


    The undersigned *

    DOB *

    (dd/mm/yyyy) *

    Resident in*

    Address *

    E-mail*


    DECLARES

    that they wear an ocular prosthesis applied by Dalpasso s.r.l. with registered office in Reggio Emilia, via Turri n. 10 *

    that they are aware of the legal consequences of providing false data or information *

    that they have been informed by Dalpasso s.r.l. regarding the standards that govern the processing of sensitive data pursuant to Legislative Decree 196/2003 *

    holding harmless Dalpasso s.r.l. from all responsibility in relation to this request*


    REQUESTS

    a copy of the photographic digital images taken and stored in the magnetic archives of the company Dalpasso s.r.l. to be sent to them.

    date on which photographs were taken *

    For that purpose chooses the following support for the requested images:
    CD Rom to be sent by post with costs charged to the addressee *

    Email to be sent to the following address: *

    I will provide a photocopy of a form of identification as soon as possible via: *


    PRIVACY

    The undersigned acknowledges the information notice provided pursuant to Art. 13 of Legislative Decree 196/2003 and provides consent for their personal data to be processed for the aims indicated and to be subject to communication to the parties and for the purposes stated.