Inscription form

Tell us about the child and their caregiver to start the Dos Hemisferios Foundation's accompaniment program.

Patient's full name

Patient's birth date

Patient's birth city

Patient's birth country

Patient's ID document

Current city of residence

Current country of residence

Diagnosis

Treatments received

Caregiver's full name

Caregiver's ID document

Caregiver's email

Caregiver's phone

Tell us the most important part of your story0/200 characters

I authorize the Dos Hemisferios Foundation, identified through the email doshemisferiosunpuentedeamor@gmail.com, as data controller, to collect and process the patient's personal data registered here — including sensitive health data (diagnosis) — for the exclusive purpose of enrollment and follow-up in the accompaniment program for children with neurological conditions and their families. I understand that, since this involves sensitive data and a minor, I am not required to authorize its processing, and that I grant this authorization as the patient's legal representative. I may access, update, correct, or request deletion of this data by writing to doshemisferiosunpuentedeamor@gmail.com.Required