Data Subject Access Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill in the information below. The website administrator or data protection officer will be notified of your request within 24 hours, and will need an appropriate amount of time to respond.

Website

Your Name

What email address do you use to access the above website?

You are submitting this request as

The person, or the parent / guardian of the person, whose name appears above.

An agent authorized by the consumer to make this request on their behalf.

Clear selection

Under the rights of which law are you making this request?

I am submitting a request to ___________

Know what information is being collected from me

Have my information deleted

Opt out of having my data sold to third parties

Opt in to the sale of my personal data

Access my personal information

Fix inaccurate information

Receive a copy of my personal information

Opt out of having my data shared for cross-context behavioral advertising

Limit the use and disclosure of my sensitive personal information

Other (please specify in the comment box below)

Other:

Clear selection

Please leave details regarding your action request or question.

I confirm that *

Under penalty of perjury, I declare all the above information to be true and accurate.

I understand that the deletion or restriction of my personal data is irreversible and may result in the termination of services with Glendale Heights Family Dental.

I understand that I will be required to validate my request by email, and I may be contacted in order to complete the request.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms