Explicit Consent Text

Within the scope of the Turkish Personal Data Protection Law No. 6698 (“KVKK”), I hereby acknowledge and declare that I have read the KVKK Privacy Notice provided to me by Dr. Kuyumcu Dental Clinic and that I have been informed about the purposes, legal grounds and methods by which my personal data may be processed.

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
Website: drkuyumcu.com
E-mail: akinkuyumcu@yahoo.com

Processing of Personal and Health Data

I have been informed that Dr. Kuyumcu Dental Clinic may process my identity and contact information, together with data relating to my oral and dental health, including examination findings, medical history, radiographic images, intraoral and extraoral clinical images, diagnosis, treatment plans and other health data generated during the treatment process, for the purpose of providing healthcare services.

I understand that health data required for medical diagnosis, treatment and care may, where permitted under the KVKK and applicable healthcare legislation, be processed without relying on explicit consent where another lawful basis applies.

This Explicit Consent Form therefore applies only to processing activities for which explicit consent is legally required or which are not necessary for the provision of essential healthcare services.

1. Processing of Non-Essential Visual and Audio Data

Where photographs, videos or similar visual or audio recordings are not strictly required for the provision of my treatment, I indicate my preference regarding their processing for the purposes specifically explained to me as follows:

[ ] I CONSENT
[ ] I DO NOT CONSENT

I understand that this choice does not prevent Dr. Kuyumcu Dental Clinic from processing clinical images that are medically necessary for diagnosis or treatment where such processing is permitted by law.

2. Use for Scientific and Professional Education Purposes

Provided that information directly identifying me is removed or anonymized to the extent reasonably possible, I indicate my preference regarding the use of appropriate clinical data or images relating to my treatment for scientific meetings, professional education, presentations or academic purposes as follows:

[ ] I CONSENT
[ ] I DO NOT CONSENT

I understand that giving such consent is not a condition for receiving healthcare services.

3. Use on the Website, Social Media and Public Digital Platforms

I indicate my preference regarding the publication or use of photographs, videos, images or other personal data relating to my treatment on drkuyumcu.com, social media accounts or other publicly accessible digital platforms as follows:

[ ] I CONSENT
[ ] I DO NOT CONSENT

I understand that refusing to provide such consent will not affect the scope or quality of the healthcare services provided to me.

4. International Transfer of Personal Data

I have been informed that, where it becomes necessary to transfer my personal data to a service provider, laboratory or technology infrastructure located outside Türkiye, such transfer must be carried out in accordance with the provisions of the KVKK governing international transfers of personal data.

I understand that international transfers may be based on lawful transfer mechanisms provided under applicable legislation, including adequacy decisions, appropriate safeguards or other legally permitted methods.

Where a specific international transfer requires my explicit consent, I understand that I will be separately informed about the relevant transfer, its purpose, recipient and possible risks, and that my specific consent may be requested where required.

Withdrawal of Explicit Consent

I have been informed that I may withdraw any explicit consent I have provided at any time with respect to processing activities based on my consent.

I understand that withdrawal of consent will apply to processing activities carried out after my withdrawal request reaches the Data Controller and will not affect the lawfulness of processing carried out prior to withdrawal.

I hereby acknowledge and declare that I have read and understood the explanations above and the Dr. Kuyumcu Dental Clinic KVKK Privacy Notice, and that I have indicated my preferences regarding processing activities requiring explicit consent freely and without pressure.

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

Turkish ID No. / Passport No.: ............................................................................

Date: …… / …… / 20……

Signature: .........................................................................…