Declaration

for obtaining dietetic counseling

I, the undersigned,

Name: ………………………………………………………………………………

in accordance with Article 6(1)(a) of the GDPR, declare that during dietetic counseling retained by MIRA Health Ltd (registered office: 1092 Budapest, Ráday Street 37, 5th floor, door 1, company registration number: 01-09-333473), as the Data Controller, based on the provisions of the Data Processing Information:

I consent to the processing of my personal data, such as name and personal data related to health necessary for dietetic counseling:

• I consent
• I do not consent

I hereby declare that:

• I have read the Data Processing Information, understood its content.

Date: ……………….., 2024, …………………month ………. day

________________________

Signature