Consumer Access Request Form

CONSUMER ACCESS REQUEST FORM

Find A Physician

Name*
Date of Birth*
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Day
Year
Telephone Number*
Address*
City*
State*
Zip Code*
Email*
If you do not have an email address, please type "none". Fields with * are required
Information Being Requested
- Specific pieces of personal information, collected or shared with third parties and for what business/commercial purpose.
- Request to delete data.
We do not sell personal information that we have collected from consumers to any third parties. By completing this form, you are making a Consumer Access request under California Consumer Privacy Act for personal information collected, held and disclosed about you that you are entitled to receive. On this date , I affirm that I am the consumer, or authorized by the consumer to act on their behalf. I understand that misrepresentation may be subject to legal action.
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Resurgens Surgery Center

Resurgens Surgery Center provides links to web sites of other organizations in order to provide visitors with certain information. A link does not constitute an endorsement of content, viewpoint, policies, products or services of that web site. Once you link to another web site not maintained by Resurgens Surgery Center, you are subject to the terms and conditions of that web site, including but not limited to its privacy policy.

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