Participant ID 1234567
Informed Consent for Medical Intervention
I, Ann Smith, 01.01.1981, Al Marsa Street, 66 Dubai Marina___________________________________________________________________________________________________________________________________________________________________________________(Full Name, Date of Birth, Address of Registration, Address of Residence (also specified if different from theregistration address)):the legal representative of the minor
John Smith, 04.04.2004____________________________________________________________________________________________________________________________________________________________________(Full Name of Minor, Date of Birth, Address of Residence (to be specified if residing separately from the legal
representative))
give informed voluntary consent for the person for whom I am the legal representative to receive 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 when choosing 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 forlaboratory testing of biological material at the Federal Budgetary Institution of Healthcare “Federal Hygienic andEpidemiological Center” of the Federal Service for the Oversight of Consumer Protection and Welfare, provision ofmedical services to take a smear for laboratory testing of biological material. The medical service for laboratory testingof 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 the Federal Service for the Oversight of Consumer Protectionand Welfare; for patients receiving the service in St. Petersburg – by the Federal Hygienic and Epidemiological Centreof St. Petersburg and the Leningrad Region; for patients receiving the service in Vladivostok – by the Federal Hygienicand Epidemiological Centre of the Primorsky Territory or by the Federal Hygienic and Epidemiological Centre of theFederal Service for the Oversight of Consumer Protection and Welfare, depending on the testing location and type ofresearch 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 forSpecialized Types of Medical Care, Regional Children’s Clinical Hospital No. 1, Regional Children’s Clinical
Hospital No. 2, Regional Clinical Psychiatric Hospital, Regional Blood Transfusion Station, Regional Narcological
Dispensary, Primorsky Regional Clinical Hospital No. 1, Primorsky Children’s Regional ClinicalPhthisiopulmonology 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 of 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 the health of the person I am legally representing may be disclosed to persons selected by
me in accordance with paragraph 5 of part 3 of article 19 of the Federal Law of 21 November 2011, No. 323-FZ “On
the Fundamentals of the Protection of Citizen’s Health in the Russian Federation”.
Mary Smith, +00 111 222 3333__________________________________________________________________(Full Name of Selected Person, Contact Number.)_____________________________________________________________________________________________(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, Date of Birth, Document (Passport) Series, Number, Issuing Authority, Date of Issue)

the legal representative of the minor John Smith ___________________________________________________(Full Name of the Minor. In case of guardianship, specify details of the document on the basis of which
guardianship or custody is exercised)assigned to me ___son______________, registered at the address:_ Al Marsa Street, 66 Dubai Marina ________________________________________________________________I, being the legal representative of the minor, in accordance with Federal Law of 27 July 2006 No. 152-FZ "OnPersonal Data", in order to provide medical services to the specified minor, confirm my consent to the processing ofmy personal data by the Federal Budgetary Institution of Healthcare "Federal Hygienic and Epidemiological Center"of the Federal Service for the Oversight of Consumer 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), 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 medicalcare, and health status data, including medical history, for the purpose of receiving medical services and ensuring
compliance with 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 theminto information repositories (electronic databases, lists, registers). The storage period of personal data corresponds tothe 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)