By filling out this form, I consent and fully authorize Regional Hospital Ltd. to process any information, which is specified by me in the form, including the processing of data of a special category envisaged by the legislation of Georgia in order to provide and / or organize the provision of medical service(s) / consultation to me. I also agree that the Regional Hospital Ltd. will use the email and phone number indicated on the form for the purpose of advertising message(s) / marketing.