Explicit Consent Text for the Processing of Patient and Patient Relative Personal Data

I have read and understood the “Clarification Text on the Processing of Personal Data of Patients and Patient Relatives”, and in this context, I accept, declare, and undertake the following:

I declare my consent for my personal data to be collected, recorded, processed, preserved, stored, and transferred as specified below by the data controller [DATA CONTROLLER TITLE] and its data processors acting as registered employees, within the framework of the principles stipulated in the relevant legislation.

In accordance with the Personal Data Protection Law No. 6698 and relevant legislation, I accept and declare that I give my explicit consent for all my personal data identifying or capable of identifying me, my special categories of personal data, and my health data to be processed, stored, and shared by [DATA CONTROLLER TITLE] within the scope below.

Personal data within the scope of this text includes all types of data belonging to an identified or identifiable natural person, particularly first and last name, TR Identity Number, contact information like phone, address, email, and IP address, Social Security number, tax number, signature information, video and audio recordings including camera records, photographic records, biometric data, and health data.

For my personal and special categories of personal data mentioned above;

1. Being processed, stored, and transferred by [DATA CONTROLLER TITLE] and its data processors

☐ I approve ☐ I do not approve

2. Being transferred to domestic and international suppliers such as financial advisors, legal consultants, and IT/software service providers, strictly limited to the services received

☐ I approve ☐ I do not approve

3. Being transferred to other healthcare institutions and organizations for the purpose of obtaining a second opinion or consultation

☐ I approve ☐ I do not approve

4. Being transferred to private insurance companies and relevant institutions within the scope of provision and billing processes

☐ I approve ☐ I do not approve

5. The processing and storage of medical photographs and images to be taken during the treatment process

☐ I approve ☐ I do not approve

6. The delivery of appointment reminders and campaign information to me via email, SMS, or phone

☐ I approve ☐ I do not approve

7. The transfer of my health data to relevant organizations within the scope of overseas laboratory and consultation services

☐ I approve ☐ I do not approve

I declare that I have given this explicit consent declaration of my own free will, without being under any pressure, and that I know I have the right to withdraw my consent at any time.

Name – Surname : ______________________________

Date : ______________________________

Signature : ______________________________