DR. ARSLAN POLYCLINIC DATA SUBJECT APPLICATION FORM

This Application Form has been prepared by DR. ARSLAN POLYCLINIC, acting as the data controller, in order to promptly evaluate and resolve applications submitted by data subjects pursuant to Articles 11 and 13 of the Law No. 6698 on the Protection of Personal Data (“Law”) and Article 5 of the Communiqué on the Procedures and Principles of Application to the Data Controller (“Communiqué”).

  1. APPLICATION METHOD

As a personal data subject, you may submit your requests regarding your rights under the KVKK to DR. ARSLAN POLYCLINIC, acting as the data controller, by completing this Application Form;

  • You may send your written application bearing your wet signature to the address of DR. ARSLAN POLYCLINIC,
  • You may send it through a notary public,
  • You may submit it to “www.drarslanklinik.com by using a secure electronic signature, mobile signature, or the electronic mail address previously notified to the data controller by the relevant person and registered in the data controller’s system.
  1. INFORMATION REGARDING THE DATA SUBJECT

Contact Information of the Applicant

Name and Surname*

Turkish Republic Identification Number*

Address*

Telephone Number* and/or Fax Number

E-Mail Address*

(*) Mandatory fields.

Your personal data submitted to us above is processed for the purposes of evaluating and finalizing this Application Form and contacting you.

  1. RELATIONSHIP OF THE DATA SUBJECT SUBMITTING THE APPLICATION WITH OUR INSTITUTION/COMPANY/HOSPITAL:

(X) Explanation Please specify, if any

Employee

Former Employee

Customer

Business Partner

Visitor

Other

  1. REQUESTS OF THE DATA SUBJECT

YOUR REQUEST REQUIRED INFORMATION/DOCUMENT YOUR SELECTION (X)

1. I would like to learn whether my personal data is processed by DR. ARSLAN POLYCLINIC. If you would like to receive information regarding a specific type of data, please specify.

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( )

2. I would like to learn for what purpose my personal data is processed by DR. ARSLAN POLYCLINIC. If you would like to receive information regarding a specific type of data, please specify.

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( )

3. I would like to learn whether my personal data is used by DR. ARSLAN POLYCLINIC in accordance with the purpose of processing. If you would like to receive information regarding a specific type of data, please specify.

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( )

4. If my personal data is transferred to third parties domestically or abroad, I would like to know the third parties to whom it has been transferred. If you would like to receive information regarding a specific type of data, please specify.

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( )

5. I believe that my personal data has been processed incompletely or inaccurately, and I request that it be corrected. Please specify the information that you believe has been processed incompletely or inaccurately and how the correct information should be.

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( )

6. I also request that my personal data, which I believe has been processed incompletely or inaccurately, be corrected before the third parties to whom it has been transferred. Please specify the information that you believe has been processed incompletely or inaccurately and how the correct information should be.

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( )

7. I request the deletion/destruction of my personal data due to the disappearance of the reasons requiring its processing. Please specify which data is subject to this request and what result you believe is against you, and include supporting information and documents regarding these matters as an attachment to the Application Form.

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( )

8. I request the deletion/destruction of my personal data before the third parties to whom it has been transferred due to the disappearance of the reasons requiring its processing. If this request relates only to a part of your personal data, please specify which data it concerns and the reason for your request together with supporting information and documents, and include such supporting information and documents as an attachment to the Application Form.

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( )

9. I believe that my personal data processed by DR. ARSLAN POLYCLINIC has been analyzed exclusively through automated systems and that a result against me has arisen as a result of this analysis.

I object to this result.

Please specify the reason for your request and the outcome of the matter regarding your request for information, and include supporting information and documents regarding these matters as an attachment to the Application Form.

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( )

10. I request compensation for the damages I have suffered due to the unlawful processing of my personal data. Please specify the reason for your request and the damage you believe you have suffered in the space below; and include supporting information and documents regarding these matters, such as decisions of the Personal Data Protection Board or court decisions, as an attachment to the Application Form.

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( )

For applications to be made by third parties on behalf of the data subject, a notarized power of attorney must be submitted together with this Application Form. For applications to be made on behalf of children under custody/guardianship, a copy of the documents proving the custody/guardianship relationship must be submitted together with this Application Form.

In order to ensure the security of your personal data, when your request for information reaches us, DR. ARSLAN POLYCLINIC may contact you to verify that you are the data subject and may request certain information and documents from you in this regard. Within this scope, the information and documents you provide to us will be used solely for the purpose of verifying that you are the data subject and will be destroyed immediately after verification.

If the requested information and documents are incomplete, the missing information and documents must be completed and submitted to us upon the request of DR. ARSLAN POLYCLINIC. Until the information and documents are fully submitted to us, the thirty (30) day period specified in Article 13/2 of the KVKK for finalizing the request will be suspended.

5. FINALIZATION OF THE DATA SUBJECT’S REQUEST

Depending on the nature of your request, it will be responded to as soon as possible and no later than thirty (30) days from the date it reaches us, pursuant to the KVKK. Our responses and evaluations will be delivered to you in writing or electronically pursuant to Article 13 of the KVKK, according to your selection specified in this Application Form. If you have a preferred method for receiving the application result by post, e-mail, or fax, please specify it below:

I would like the result of my application to be sent to my e-mail address.

( ) I would like the result of my application to be sent to my address by post.

( )

I would like the result of my application to be sent by fax. ( )

6. DATA SUBJECT DECLARATION

I hereby request that my application for information regarding my rights under the KVKK be evaluated and finalized within the scope of the request(s) stated above, and I accept, declare, and undertake that the information and documents I have provided to you in this application are accurate, up to date, and belong to me.

Data Subject;

Name-Surname:

Signature: