Data Subject Application Form

Under the Turkish Personal Data Protection Law No. 6698 (“KVKK”), individuals defined as “Data Subjects” are granted certain rights under Article 11 of the Law.

You may use this form to submit your requests regarding your rights under the KVKK to the data controller, Dr. Kuyumcu Dental Clinic.

Data Controller: Dr. Kuyumcu Dental Clinic
Address: Plevne Bulvarı No:19, Emek 1 Apt. Floor:3, Apartment:7, Alsancak / İzmir, Türkiye
Telephone: (0232) 421 90 70
E-mail: akinkuyumcu@yahoo.com
Website: drkuyumcu.com

Application Methods and Contact Channels

You may submit this completed form to us using one of the following methods:

Written Application:
You may personally deliver the signed application form or send it through a notary public to:

Plevne Bulvarı No:19, Emek 1 Apt. Floor:3, Apartment:7, Alsancak / İzmir, Türkiye

Registered Electronic Mail (KEP), Secure Electronic Signature or Mobile Signature:
You may submit your application using electronic application methods that meet the requirements prescribed under applicable legislation.

By E-mail:
You may submit your application using an e-mail address that you have previously provided to Dr. Kuyumcu Dental Clinic and that is registered in our systems, by sending it to:

akinkuyumcu@yahoo.com

Important: As a general rule, the application must be made by the Data Subject personally. Where an application is made on behalf of another person, documentation demonstrating the applicant’s legal authority must be submitted. Applications made by a parent, guardian or authorized representative must be accompanied by the relevant authorization documents.

Where necessary to verify the identity of the applicant, Dr. Kuyumcu Dental Clinic may request additional information or documentation. Only information necessary for identity and authorization verification will be requested.

1. Information Regarding the Applicant

Please complete the following fields fully and legibly.

Full Name:
..............................................................................................................

Turkish Republic ID Number:
..............................................................................................................

For Foreign Applicants – Nationality / Passport No. / Identification No.:
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Residential or Business Address for Notifications:
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Mobile Telephone:
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E-mail Address:
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Your Relationship with Dr. Kuyumcu Dental Clinic

[ ] Patient

[ ] Patient Relative / Legal Representative

[ ] Website Visitor

[ ] Employee

[ ] Job Applicant

[ ] Supplier / Service Provider

[ ] Other: ....................................................................

Is your relationship with the clinic ongoing?

[ ] Yes

[ ] No

Year the relationship ended: ....................................

2. Your Request Under the KVKK

Under Article 11 of the KVKK, you may submit a request regarding one or more of the following rights:

[ ] I would like to learn whether my personal data is being processed.

[ ] If my personal data has been processed, I request information regarding such processing.

[ ] I would like to learn the purpose of processing my personal data and whether it is being used in accordance with that purpose.

[ ] I would like to learn the third parties to whom my personal data has been transferred in Türkiye or abroad.

[ ] I request correction of any incomplete or inaccurate personal data.

[ ] I request deletion or destruction of my personal data where the conditions prescribed under the KVKK are met.

[ ] I request that correction, deletion or destruction procedures be notified to third parties to whom my personal data has been transferred.

[ ] I object to a result arising against me through the analysis of my personal data exclusively by automated systems.

[ ] I request compensation for damages suffered as a result of the unlawful processing of my personal data.

Description of Your Request

Please describe the subject of your application and your request as clearly and specifically as possible. You may use additional pages where necessary.

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Documents Attached to Your Application

Attachment 1:
..............................................................................................................

Attachment 2:
..............................................................................................................

Attachment 3:
..............................................................................................................

3. Method by Which You Wish to Receive the Response

Please select how you would like the response to your application to be delivered:

[ ] By E-mail
I would like the response to be sent to the e-mail address specified in this form and, where required, registered in the clinic’s systems.

[ ] By Post
I would like the response to be sent to the notification address specified in this form.

[ ] In Person
I would like to collect the response personally from Dr. Kuyumcu Dental Clinic.

If the response is to be collected by an attorney or another authorized representative, documentation demonstrating that person’s authority must be presented.

4. Evaluation of the Application

Dr. Kuyumcu Dental Clinic will evaluate and conclude your application under the KVKK as soon as possible and no later than 30 days, depending on the nature of your request.

Applications are generally processed free of charge. However, where responding to the application requires an additional cost, fees may be charged in accordance with the tariff determined by the Turkish Personal Data Protection Board.

If the application is accepted, or rejected with an explanation of the grounds for rejection, the response will be communicated to the Data Subject in writing or electronically.

5. Applicant’s Declaration

I request that my application submitted under the KVKK in accordance with the matters stated above be evaluated and that I be informed of the outcome within the statutory period.

I hereby declare that the information and documents provided in this application are accurate, current and belong to me.

I acknowledge that the personal data provided within the scope of this application may be processed in accordance with applicable legislation for the limited purposes of receiving my application, verifying my identity and authority to apply, evaluating and concluding my request, and communicating the response to me.

Applicant’s Full Name:
..............................................................................................................

Application Date:
…… / …… / 20……

Signature:
..............................................................................................................

Dr. Kuyumcu Dental Clinic
Plevne Bulvarı No:19, Emek 1 Apt. Floor:3, Apartment:7, Alsancak / İzmir, Türkiye
Telephone: (0232) 421 90 70
E-mail: akinkuyumcu@yahoo.com
Website: drkuyumcu.com