Participant ID 1234567
Informed Consent for Medical Intervention

I, Ann Smith, 01.01.1981______________________________________________________________________(Full Name, Date of Birth)
Address of Registration, Address of Residence (also specified if different from the registration address):
Al Marsa Street, 66 Dubai Marina _____________________________________________________________________________________________________________________________________________________________
give informed voluntary consent to the types of medical interventions included in the List of Certain Types of Medical
Interventions. This includes the primary medical care for which citizens provide informed voluntary consent whenchoosing a doctor and medical organization, approved by order of the Ministry of Health and Social Development of
the Russian Federation dated 23 April 2012 No. 390N (hereinafter referred to as the types of medical interventions
included in the List). This includes services for laboratory testing of biological material at the Federal Budgetary
Institution of Healthcare “Federal Hygienic and Epidemiological Center” of the Federal Service for the Oversight ofConsumer Protection and Welfare, provision of medical services to take a smear for laboratory testing of biologicalmaterial. The medical service for laboratory testing of biological material is provided by organizations on a territorial
basis: for patients receiving the service in Moscow – by the Federal Hygienic and Epidemiological Centre of theFederal Service for the Oversight of Consumer Protection and Welfare; for patients receiving the service in St.
Petersburg – by the Federal Hygienic and Epidemiological Centre of St. Petersburg and the Leningrad Region; forpatients receiving the service in Vladivostok – by the Federal Hygienic and Epidemiological Centre of the Primorsky
Territory or by the Federal Hygienic and Epidemiological Centre of the Federal Service for the Oversight of Consumer
Protection and Welfare, depending on the testing location and type of research method selected. The medical service
for collecting biological material for laboratory testing (taking a smear) is provided by organizations on a territorial
basis: for patients receiving the service in Moscow – by MedLine LLC; for patients receiving the service in St.
Petersburg – by the Hygienic and Epidemiological Centre in St. Petersburg and the Leningrad Region; for patients
receiving the service in Vladivostok, depending on the testing point selected: Regional Dental Clinic, Regional
Clinical Skin and Venereal Disease Dispensary, Regional Clinical Centre for Specialized Types of Medical Care,Regional Children’s Clinical Hospital No. 1, Regional Children’s Clinical Hospital No. 2, Regional ClinicalPsychiatric Hospital, Regional Blood Transfusion Station, Regional Narcological Dispensary, Primorsky Regional
Clinical Hospital No. 1, Primorsky Children’s Regional Clinical Phthisiopulmonology Centre, Primorsky Regional
Oncology Dispensary, Primorsky Regional Perinatal Centre, Primorsky Regional Anti-Tuberculosis Dispensary,
Artyom City Hospital No. 1, Artyom Children’s Hospital, Vladivostok Children’s Polyclinic No. 2, Vladivostok
Children’s Polyclinic No. 3, Vladivostok Children’s Polyclinic No. 5, Vladivostok Clinical Hospital No. 4,Vladivostok Polyclinic No. 1, Vladivostok Polyclinic No. 3, Vladivostok Polyclinic No. 6, Vladivostok Polyclinic
No. 9, Vladivostok Clinical Maternity Hospital No. 3, Hospital for War Veterans, and Vladivostok Basic Medical
College.
The healthcare provider has thoroughly explained to me the objectives, methods of treatment, potential risks,
available medical interventions, their implications, including possible complications, and the anticipated outcomes oftreatment in a manner that I can easily understand. I have been informed that I retain the right to decline specificmedical interventions listed or to request their cessation, except in cases outlined in Part 9, Article 20 of the Federal
Law of 21 November 2011, No. 323-FZ “On the Fundamentals of the Protection of Citizen’s Health in the RussianFederation”.
Information about my health may be disclosed to persons selected by me in accordance with paragraph 5 ofpart 3 of article 19 of the Federal Law of 21 November 2011, No. 323-FZ “On the Fundamentals of the Protection ofCitizen’s Health in the Russian Federation”.
______________–_____________________________________________________________________________(Full Name of Selected Person, Contact Number. If unavailable, use a dash)____________________________________________________________________________________________(Signature)(Name of health care provider)

Date of completion 1 September 2024______Smith_________________________________________________Ann Smith_________________________(Signature)(Full name)

Participant ID 1234567
Consent to the Processing of Personal Data
I,_Ann Smith, 01.01.1981, Passport, 123456789, Ministry of…., 01.01.2011_______________________________
Full Name, Document (Passport), Series, Number, Issuing Authority, Date of Issue
Registered at the address:__ Al Marsa Street, 66 Dubai Marina _______________________________________________________________In accordance with Federal Law of 27 July 2006 No. 152-FZ “On Personal Data”, in order to provide me withmedical services, I hereby confirm my consent to the processing of my personal data by the Federal BudgetaryInstitution of Healthcare “Federal Hygienic and Epidemiological Center” of the Federal Service for the Oversight ofConsumer Protection and Welfare (INN 7726008570, address: 19A, Varshavskoye Shosse, Moscow, 117105)(hereinafter referred to as the Operator). This includes surname, first name, patronymic, date and place of birth, gender,citizenship, residence address (including registration information), workplace details, phone number, identity
document details (series, number, date of issue, issuing authority), medical insurance policy details, individual
insurance account number in the Pension Fund of Russia (SNILS), information regarding provided medical care, andhealth status data, including medical history, for the purpose of receiving medical services and ensuring compliancewith the laws and regulations of the Russian Federation.
I hereby authorize the Operator to perform all actions (operations) or a set of actions (operations) in processing
personal data, whether automated or manual, including collection, recording, systematization, accumulation, storage,
clarification (update, change), extraction, use, transmission (dissemination, provision, access), depersonalization,
blocking, deletion, destruction of personal data.
The Operator has the right to process personal data by entering them into information repositories (electronicdatabases, lists, registers).
The storage period of personal data corresponds to the storage period of medical records.
Name of entities responsible for processing personal data on behalf of the Operator by authorizing employeesof the said legal entities to process personal data, if such processing is delegated to them: Roscongress Foundation(INN 7706412930), address of location: Room 1101, Entrance 7, 12, Krasnopresnenskaya Naberezhnaya, Moscow,
123610, Hygiene and Epidemiology Centre in St. Petersburg and the Leningrad Region (Taxpayer Identification
Number 7816363890), address: 7, Volkovsky Prospekt, St. Petersburg, 192102, and Hygiene and Epidemiology
Centre in the Primorsky Territory (Taxpayer Identification Number 2536153796), address: 36, Utkinskaya Ulitsa,
Vladivostok, Primorsky Territory, 690091.
Personal data may only be disclosed to other persons or otherwise disclosed with my written consent.
I reserve the right to withdraw my consent in writing, which may be sent to the Operator by registered mailwith acknowledgement of receipt or personally delivered and signed for by the Operator's representative.
This consent is given by me and is valid for 1 (one) year, unless the consent is withdrawn in writing.
Date of completion 1 September ___________________2024_______Smith_____________________________________________Ann Smith____________________________(Signature)(Full name)