CONSENT FORM FOR THE MATERNAL HEALTH FUND (“MHF”) PROGRAM

Part 1. Consent for Program Participation & Data Processing (Required)

I acknowledge and agree to:

The Maternal Health Fund Program (“MHF” or the “Program”) is a One Global Medical Technology Ltd (“Helium Health”) initiative implemented in partnership with the Solina Centre for International Development and Research (“SCIDaR”). The Program is designed to support healthcare facilities with financing and capacity building to improve maternal healthcare outcomes in Lagos State.
By completing this form, you acknowledge that you have read the Program’s Privacy Notice and you agree to the following:

  • The collection, use, and disclosure of my Data (including personal, financial, and health-related information) for the purpose of administering and managing my participation in the Program, including loan applications, disbursements, and repayments.
  • The sharing of my Data with financial institutions, regulators, and other Program partners where necessary to deliver Program services.
  • Helium Health and Helium Health’s Affiliates contacting me regarding matters directly related to my participation in the Program, loan processing, repayment, care coordination, or healthcare services. “Affiliates” means any entity that controls, is controlled by, or is under common control with Helium Health.
  • The creation and use of de-identified Data for statistical, research, and program improvement purposes as described in the MHF’s Privacy Notice.

Part 1. Consent for Program Participation & Data Processing (Required)

  • I authorize Helium Health, Helium Health’s Affiliates and Helium Health’s Partners, to use my Data for purposes beyond my direct participation in the Program. This may include:
  • Participation in surveys, feedback initiatives, or service evaluations.
  • Opportunities to join research studies or clinical trials.
  • Updates on initiatives that advance maternal healthcare in Africa and globally, as described in the Privacy Notice.
  • Marketing or promotional communications about products, services, and initiatives that may be relevant to me.

I understand this authorization is voluntary, may be declined without affecting my participation in the Program, and can be revoked at any time by emailing dpco@heliumhealth.com.

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