By signing this ONLINE CONSULTATION FORM, you hereby allow / authorize UPH Calamba Campus and their authorized personnel to gather and process your sensitive personal information such as name, address, contact number, email address, medical condition and picture if applicable specifically for the purpose of GATHERING PERSONAL HEALTH INFORMATION FOR ONLINE MEDICAL CONSULTATION. All information gathered in this form will be kept secure and confidential for a period of 5 YEARS from the date of collection. It will be destroyed by means of shredding and/or file deletion after the prescribed retention period of 5 years in accordance with the Republic Act 10173 or the Data Privacy Act of 2012 of the Republic of the Philippines. *
