DATA SUBJECT’S EXPLICIT CONSENT DECLARATION FORM

I declare, acknowledge and undertake that I have read the Disclosure/Information Notice belonging to the Neurology Specialist Dr. Şule Bilgin, located at Mansuroğlu Mah. 1593/1 Sok. No:2 A Blok Kat:8 D:88 Bayraklı İzmir, and the Practice/Clinic operated by her (hereinafter referred to briefly as “Dentist/Doctor/Employer/Physician/Practice/Clinic”), and that, within the scope of the Personal Data Protection Law No. 6698, I give prior consent to the collection, recording, processing, transfer and storage of my personal data by the Physician and her Practice within the framework of the principles set out in the law.

Pursuant to the Personal Data Protection Law No. 6698 and the Regulation on the Processing of Personal Health Data and Ensuring Privacy, I accept, declare and undertake the following: I consent to the processing of my health data; and to the processing of all my personal data — including every kind of special category of personal data, including data that identifies or helps to identify me, provided by me orally/in writing and/or electronically — as well as my physical examination findings, tests and results, diagnosis and planned form of treatment, and my contact information, for the purposes of carrying out my examination, preventive medicine, medical diagnosis, treatment, care and control services by the Physician and her Practice, improving the medical treatment applied to me, reminding me of upcoming appointment dates in ongoing treatments, and personally informing me of innovations and developments regarding medical treatment and practices, and for the purpose of analyzing the disease from the cell and/or tissue sample taken; to its processing, and its sharing and transfer by the physician with the persons and institutions with which the physician has agreements, and with other persons and organizations with which sharing is required within the scope of the relevant legislation, and with the relatives I have specified; to the provision of health services through mobile communication and the planning of these services, and to SMS and e-mail being sent to me for celebration and congratulation on special days, and to transactions being carried out with my e-pulse (e-Nabız) information; and I consent to the processing, use and sharing of my personal data, special categories of personal data and health data detailed below within the scope defined in the Personal Data Protection Law No. 6698, the Regulation on the Processing of Personal Health Data and Ensuring Privacy, and the Regulation on Promotion and Information Activities in Health Services. I accept, declare and undertake that the content and scope of the information to be provided to me within the framework of the service and KVKK confidentiality agreements between the physician and other persons and institutions is subject to the provisions of the contract between the parties. Furthermore, I accept and declare that this consent covers my personal data provided by me orally, in writing, visually or electronically during the examination, as well as my personal data that I transmit via internet and mobile applications or electronically, or that is obtained at the practice. I accept and declare that I have been informed about the purposes of processing my personal data, the methods and legal grounds of its collection, my rights regarding the protection of my personal data, the mandatory cases in which my data may be transferred, data security and applicant rights, and that I accept and declare that all my personal data, including my health data, may be recorded, stored and, in mandatory cases, shared by the physician and her employees.

I have been informed by the physician about the MBYS and e-Nabız systems. I consent to my personal health data specified in this document being shared with the Ministry of Health, the SGK or the relevant institutions and organizations through applications such as MBYS and e-Nabız. I consent □ / I do not consent. □

– Data that is clearly attributable to an identified or identifiable natural person; processed wholly or partly by automatic means, or by non-automatic means as part of a data recording system; data containing information about the person’s identity; documents such as a driver’s licence, identity card and passport containing information such as name-surname, T.R. identity number, nationality information, mother’s name-father’s name, place of birth, date of birth and gender, as well as information such as tax number, SGK number, signature information, and the like.

– Data that is clearly attributable to an identified or identifiable natural person; processed wholly or partly by automatic means, or by non-automatic means as part of a data recording system; information such as telephone number, address, e-mail address, fax number and IP address.

– Data that is clearly attributable to an identified or identifiable natural person; processed wholly or partly by automatic means, or by non-automatic means as part of a data recording system; personal data relating to records and documents taken upon entry to a physical space and during the stay within the physical space; camera recordings, fingerprint records and records taken at the security point.

– Data that is clearly attributable to an identified or identifiable natural person; photographs and camera recordings (excluding records falling within the scope of Physical Space Security Information), and data contained in documents that are copies of documents containing personal data.

– Data that is clearly attributable to an identified or identifiable natural person; processed wholly or partly by automatic means, or by non-automatic means as part of a data recording system; the data specified in Article 6 of the Personal Data Protection Law (e.g. health data including blood type, biometric data, etc.).

– Data that is clearly attributable to an identified or identifiable natural person; processed wholly or partly by automatic means, or by non-automatic means as part of a data recording system; personal data relating to the receipt and evaluation of any kind of request or complaint directed to the Physician and her Practice.

I have read and accept the Disclosure/Information text on the Protection and Processing of Personal Data by the Physician and her Practice, and my rights, both from the physician’s web address and/or physically. I accept, declare and undertake that, in the event it is determined that the personal data I have shared with the Physician and her Practice was obtained without the explicit consent of its owner and/or unlawfully, and that in the event sanctions are applied against the Physician and her Practice by relevant third parties, data subjects or the Personal Data Protection Board and other administrative and judicial bodies, and the Physician and her Practice suffer damage for this reason, the responsibility for compensating every kind of criminal and legal liability and every kind of damage belongs to me; that I have read and reviewed the disclosure/information text of the Physician and her Practice, and that I accept it knowingly and with an understanding of all the matters stated; and that, of my own free will, I give explicit consent to the processing, use and transfer of my personal data within the scope defined in the KVK Law. I GIVE MY CONSENT.

NAME SURNAME / Parent/Guardian DATE SIGNATURE