Application Form

ESRA BILGEN

DATA CONTROLLER APPLICATION FORM

In the Law on the Protection of Personal Data with No. 6698 (“Law”) the personal data owners identified as the relevant person (“Relevant Person”), provided with certain rights regarding the processing of personal data in Article 11 of the Law.

According to paragraph 1 of Article 13 of the Law; Applications to be made to our Clinic, which is data controller, regarding these rights must be submitted in writing or delivered through other methods determined by the Personal Data Protection Board (“Board”).

Within this framework, applications to be made to our clinic in “writing” should be made by taking the printout of this form and processing as follows;

• By personal application of the applicant
• By means of a notary public,
• By appending the electronic signature of the applicant as defined in the Electronic Signature Law with No. 5070 as “secure electronic signature” and sending it to the registered electronic e-mail address of the Clinic
• Submission of the application with electronic signature or application with an e-mail.

According to paragraph 1 of Article 13 of the law; the above-mentioned channels are the channels for “written application”. After other methods determined by the Board, such methods will be announced by our clinic on how applications will be received through these methods.

                                                           ESRA BILGEN

Identity and contact information of the applicant data owner:

Identity and contact information of the representative who submitted the application on behalf of the data owner :

(This section will be filled in if there is a proxy who applies on behalf of the data owner.)

Please indicate your relationship with our Clinic: (Such as “Patient, visitor, business partner, employee, employee candidate, intern, former employee, employee of a third-party company, other (please specify)”)

Please specify your request within the scope of KVKK in detail. If there is information and documents related to the subject, they should be annexed to the application.                                                 ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Please choose the method of notification of our response to your application:

• I want it sent to my address.
• I want it sent to my e-mail address.
• I want to take the delivery by hand.

(In case of receipt by proxy, there must be a power of attorney or a document indicating the authority of the authorized person.)

This application form has been prepared in order to determine your relationship with our Clinic, to determine your personal data processed by our Clinic in full, if any, so that your relevant application can be responded correctly and within the legal period. In order to eliminate legal risks that may arise from illegal and unfair data sharing and particularly to ensure the security of your personal data, our Clinic reserves the right to request  additional documents and information (a copy of identity card or driver’s license, etc.) for identification and authorization.).

According to Article 7 of the “Communiqué on the Procedures and Principles of Applying to the Data Controller” If the transaction subject to your request requires an additional cost, you may be charged according to the tariff determined by the Personal Data Protection Board. If the information about your request that you submit within the scope of the form is not correct and up-to-date, or if an unauthorized application is made, our Clinic does not accept any liability for such outdated information, incorrect information, or requests caused by an unauthorized application.

The processes related to this form are carried out in accordance with the KVKK with no 6698 and other legislation, the principle decisions of the Personal Data Protection Board, the Data Processing and Data Destruction Policies of Esra Bilgen.