Applicant Information
- Full Name:
- Turkish ID Number:
- Phone Number:
- E-mail:
- Address:
- Your relationship with our clinic (Patient, relative of patient, business partner, job applicant, third-party company employee, shareholder, etc.):
Selection of Rights to Be Exercised by the Data Subject
(Please check the box(es) corresponding to your request)
- I want to know whether your clinic processes my personal data.
- If your clinic processes my personal data, I request information about these processing activities.
- If your clinic processes my personal data, I want to know the purpose of processing and whether the data is used in accordance with that purpose.
- I want to know the third parties to whom my personal data is transferred domestically or abroad.
- I believe my personal data is incomplete or inaccurate and request it to be corrected.
- I request the deletion of my personal data that has been processed in accordance with the law and other relevant regulations.
- I request that incomplete or inaccurate personal data be corrected with the third parties to whom it has been transferred.
- I request that my personal data, which I have requested to be deleted, be deleted with the third parties to whom it has been transferred.
- I believe that my personal data processed by your clinic has been analyzed exclusively through automated systems and that this analysis resulted in an adverse outcome for me. I object to this outcome.
Explanation About Your Request
(Please specify your request under the Personal Data Protection Law and the personal data concerned in detail)
Attachments
(Please list any documents supporting your request)
Preferred Method for Receiving Our Response
- I want it sent to my address.
- I want it sent to my e-mail (This option allows for a faster response.)
- I want to receive it in person (If collected by proxy, a notarized power of attorney or authorization document is required.)
Applicant Declaration
This application form has been prepared to identify your relationship with Özel İncident Oral and Dental Health Clinic and, if any, to accurately specify your personal data processed by our clinic, in order to respond to your request correctly and within the legal timeframe. To prevent legal risks arising from unlawful or improper data sharing and to ensure the security of your personal data, our clinic reserves the right to request additional documents (e.g., a copy of your ID card or driver’s license) for identity verification. The clinic does not accept responsibility for requests resulting from inaccurate, outdated, or unauthorized information provided. Any liability arising from unlawful, misleading, or incorrect applications rests solely with the applicant.
Data Subject / Applicant on Behalf of Another Person
- Full Name: ………………………………
- Application Date: ………………………………
- Signature: ………………………………
Note: If applying on behalf of someone else, please attach documents showing your authorization (e.g., proof of guardianship, power of attorney). These documents must be issued or approved by authorized authorities to be considered valid.