Subject Access Request Form

Under the Nigeria Data Protection Regulation 2019, you have a right to access personal information that Avon Medical holds about you. However, as a healthcare provider dealing with a wide range of policies, we could hold personal information in a number of different areas. Completing this form will help us to locate the information you are seeking and deal with your request as quickly as possible.

    Part 1 – About Yourself





    Part 2 – Locating Your Personal Information

    In order for us to be able to locate the information you are seeking, please provide some details, if known, as to where you feel information is held about you. If you would like to provide any further information that you feel would be helpful in locating your personal information, please provide this in the box named Additional Information.

    Part 3 – Confirming Your Identity

    Please provide proof of address and identification. For identity purposes please send a copy of one of the following documents listed below. Hard copies of documents will be returned once the search is completed.

    Proof of Identification can include:

    • Photocopy of passport
    • Photocopy of Driver’s License



    Proof of address can include:

    • Original of electricity bill
    • Original of any other bill in your full name
    • Bills should not be more than six months old

    Part 4 - Declaration

    Please read the following statement carefully and use the checkbox after it to accept the declaration:

    I certify that the information provided on this application to Avon Medical is true. I understand that it is necessary for Avon Medical to confirm the data subject’s identity and that it may be necessary for Avon Medical to request more details from me in order to be able to locate the correct information.




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