Pursuant to Law No. 6698 on the Protection of Personal Data ("KVKK"), individuals defined as "Data Subjects" under the Law are granted certain rights under Article 11. By completing this form, you may submit your requests regarding these rights to the Data Controller, Dr. Dt. Ebru Çetinkaya Tokmak.
Application Methods and Contact Information
You may submit this completed form using one of the following methods:
Written Application (In Person or via Notary Public):
By delivering a signed hard copy to:
Konacık Mah. Fatih Sultan Mehmet Cad. No:4/Ahmet Yesevi Mah. Sanayi Cad. Üründül Plaza No:517C, 16140 Nilüfer/Bursa
By E-mail:
By sending the form signed with a secure electronic signature or mobile signature, or from the e-mail address registered in our system, to:
info@ebrucetinkaya.com
IMPORTANT NOTICE: Applications must be submitted personally by the data subject. Applications submitted on behalf of a spouse, relative, child (unless legal guardianship or custodianship is documented), or any other third party will not be accepted. If our Practice/Clinic has reasonable doubt regarding the identity of the applicant, additional verification documents (such as a copy of an identity document) may be requested. The Practice/Clinic accepts no responsibility for applications submitted using inaccurate, incomplete or unauthorised information.
1. APPLICANT INFORMATION
Please complete all fields below in BLOCK CAPITAL LETTERS.
Full Name:
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Turkish Republic ID Number / Passport Number:
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Correspondence Address:
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Mobile Phone:
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E-mail Address:
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Your Relationship with Our Clinic:
☐ Patient
☐ Visitor
☐ Employee / Job Applicant
☐ Supplier
☐ Other: ....................................................
Is Your Relationship with Our Clinic Ongoing?
☐ Yes
☐ No (Year Relationship Ended: ................................)
2. DETAILS OF YOUR REQUEST
Please describe your request under the KVKK in detail below.
(You may attach additional pages if necessary.)
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If you are submitting supporting documents, please list them below:
Attachment 1:
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Attachment 2:
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3. PREFERRED METHOD OF RESPONSE
Please indicate how you would like to receive our response.
☐ By E-mail
I request that the response be sent to the e-mail address provided in this form.
(This is the fastest response method.)
☐ By Registered Mail
I request that the response be sent by registered mail to the correspondence address provided above.
☐ Collection in Person
I wish to collect the response personally from the Practice/Clinic.
(Where collection is made by an authorised representative, a notarised power of attorney must be presented. Responses will not be released to relatives or third parties without proper legal authorisation.)
4. APPLICANT'S DECLARATION AND SIGNATURE
I respectfully request that my application be evaluated in accordance with the requests stated above and that I be informed within the statutory period of 30 (thirty) days.
I declare and undertake that all information and documents provided in this application are accurate, complete, up to date and belong to me, and that I consent to their processing solely for the purposes of evaluating my application, responding to my request and verifying my identity.
Applicant's Full Name:
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Date of Application:
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Signature:
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