Ethics Review Form

An Ethics Committee has been established to provide independent guidance on ethical or philosophical questions related to your care. Made up of qualified healthcare professionals, it is there to support you when you are facing moral dilemmas or important decisions concerning your fundamental rights and autonomy. The committee is accessible to patients and their relatives. You are welcome to submit your questions or concerns in order to receive thoughtful, objective guidance.

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Phone

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First name*

Last name*

E-mail*

Phone*

You are*

Submission of a Request for an Ethical Review

Background of the request*

Issue requiring an ethical opinion*

Other information:

All requests will be treated as strictly confidential.
The information you provide in this form will be shared exclusively with and accessible only by the Ethics Committee Secretariat.
The Ethics Committee may contact the parties involved during its review of the case in order to gather the information necessary to formulate its opinion.
The processing of personal data is carried out in strict compliance with applicable data protection laws.
The request, as well as the opinion issued by the ethics committee, shall also be subject to medical confidentiality if they contain information covered by medical confidentiality.

To fill out the form, please contact the department manager so they can assist you.

Consent*

By checking this box, I expressly consent to my health data (medical information, details regarding assistance and care, and my individual file)—which the ethics committee requires to make an informed decision—being processed exclusively by the committee for the purpose of handling my request.

Please be advised that if you do not consent to the processing of the above health data, the ethics committee will not be able to process your request. You may withdraw your consent at any time.

Consent*

By checking this box, I acknowledge that I have read the privacy policy

Please review our privacy policy.