Personal Information Removal/Copy Request Form

For privacy reasons, you may have the right to ask for certain personal information relating to you to be removed.

This form is for requesting the removal of specific InstaConsult submissions. i

If you want to request removal of personal information please submit the request form below.

Fields marked with an * are required

I am acting on behalf of... * If you are submitting this request on behalf of someone else, please specify your relationship to that person (for example: "parent", "attorney"). We may ask for documentation confirming that you are authorized to represent this person.

Have you filed a previous request?

Reason for removal/Get a Copy of submission*

Data Request

Full Name used on submission *

SWORN STATEMENTS
Please read the following statements, and check the boxes to confirm that you have read and acknowledge them.

I have read and acknowledge the explanation of the processing of the personal information that I am submitting, as outlined below: *

InstaConsult will use the personal information that you supply on this form (including your email address and any ID information) and any personal information you may submit in further correspondence for the purposes of processing your request and meeting our legal obligations. We may share details of your request with data protection authorities, but only when they require these details to investigate or review a decision that we have made.

I represent that the information in this request is accurate and that I am authorized to submit this request. *

I understand that InstaConsult will not be able to process my request if the form is not properly filled out or if the request is incomplete. *

Signed on this date of: *

Signature: *

e.g. John A. Smith By typing your full name above, you are providing us with your digital signature, which is as legally binding as your physical signature. Please note that your signature must exactly match the first and last names that you entered at the top of this web form in order for your submission to be successful.

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Personal Information Removal/Copy Request Form