I hereby give my consent and authorize Establishment Labs Holdings Inc. and / or its affiliates (collectively referred to as "Establishment Labs") for the processing and transfer, within and outside the country, of my Personal Information mentioned below (hereinafter "Personal Information"):
- Name of the clinic or center
- Professional Address
- Professional website address
- Professional social media links
- Professional phone number
- Professional e-mail address
- Professional images
- Description of surgeon, clinic or center
- List of performed procedures
Establishment Labs has informed me and, as a result, I acknowledge that the purpose of the delivery of Personal Information is solely for the following purposes:
Public availability at https://motiva.health/patients/find-a-surgeon/
I understand, acknowledge and agree that Personal Information may be stored in print or electronically and may be accessible to Establishment Labs employees, inside and outside the country in which consent is granted.
I understand the content of this format, but if I have any doubt about any of the terms contained therein, I may request from Establishment Labs any clarification it deems necessary.
I declare that my consent is voluntary, that Establishment Labs does not obligate me to sign this Consent Form and that I have all the freedom to refuse to sign it.
This consent is granted for an indefinite period. In any case, I have the right to revoke my consent at any time. Any request regarding Personal Information, including revocation, must be made in writing and delivered to the Data Privacy Officer through the email address firstname.lastname@example.org or in writing sent to Establishment Labs located in Free Zone Coyol, Building B25, Alajuela, Costa Rica. Telephone (506) 24342400. From the day the revocation is delivered to the Establishment Labs representative, it will have 30 (thirty) days to respond to my request.