TR
EN
RUPROCESSING OF THE PERSONAL DATA OF THE PATIENT AND THE PATIENT'S RELATIVE
EXPLICIT CONSENT STATEMENT
Prof. Dr. Murat Kılıç Practice has provided me with the “Privacy Notice” prepared in accordance with the Personal Data Protection Law No. 6698, and by reading it I have been informed in detail and clearly about what personal data and special categories of personal data are, for what purposes personal data, including special categories, will be processed, to whom and for what purposes my processed personal data may be transferred, the method and legal basis of collecting personal data, and my rights.
In accordance with all of this information and the privacy notice;
- All of my personal data;
provided before today and to be provided after today, and collected and to be collected in the ways stated in the privacy notice from the moment I first contacted the practice acting as data controller (including, without being limited to those mentioned at the outset: my identity data, my contact details, my financial information, my insurance data, my indoor camera footage, etc.)
- All personal data of my child under my custody whom I have brought for treatment;
provided before today and to be provided after today, and collected and to be collected in the ways stated in the privacy notice from the moment we first made contact with the practice acting as data controller, including special categories of data (the identity data, contact details and indoor camera footage of persons under my custody and guardianship, laboratory results reports, photos/videos related to the complaint (data sent through WhatsApp and similar applications), information on past operations, information on past treatments, medication use information, weight, height, prescriptions, laboratory results, examination notes (epicrisis), and, without being limited to these, all kinds of health data obtained during or as a result of medical diagnosis, treatment and care services)
I consent, of my own free will and knowingly, to: their processing by the practice, limited to the data processing purposes stated in the privacy notice previously provided to us (a copy of which has been given), primarily in order to fulfil the legal obligations set out in the Personal Data Protection Law No. 6698 and other related regulations; our being contacted by phone/text message/e-mail; the processing, recording, storage and retention of my personal data and of the personal and special-category data of my child under my custody through these and similar channels; the sharing of health data concerning me and my child under my custody with the relatives who are with me during the examination; their transfer, acquisition and assignment within the country to the third parties named in the privacy notice; and the retention of all special-category personal data of my child under my custody for 15 years;
I consent / I do not consent.
Patient's Full Name:
Patient's Relative's Full Name/Degree of Relationship:
Date: Signature:
