Name *

First Name

Last Name

You are submitting this request as *

The person, or the parent / guardian of the person, whose name appears above.

An agent authorized by the consumer to make this request on their behalf.

I am submitting a request to - *

Know what information is being collected from me

Have my information deleted

Other (please specify in the comment box below)

I confirm that *

Under penalty of perjury, I declare all the above information to be true and accurate.

I understand that the deletion or restriction of my personal data is irreversible and may result in the termination of services with Ms.Medicine.

I understand that I will be required to validate my request by email, and I may be contacted in order to complete the request.