Explicit Consent Form for Processing Personal Data of Patients and Patient Relatives

I have read the Privacy Notice Regarding the Processing of Personal Data of Patients and Patient Relatives, and in this context:

I hereby state that I give my prior consent for my personal data to be retained, transferred, collected, recorded, processed, and stored by the data controller Assoc. Prof. Dr. Hamza Yıldız Clinic and data processors Assoc. Prof. Dr. Hamza Yıldız Clinic (clinic staff) within the framework of the law, and I accept, declare, and undertake that it may be shared as specified below.

Pursuant to Law No. 6698 on the "Protection of Personal Data" and the "Regulation on the Processing and Ensuring the Confidentiality of Personal Health Data," I accept, declare, and undertake that I consent to the processing and sharing of my personal data, special categories of personal data, and health data — including all types of personal data that identify or can be used to identify me, whether provided verbally/in writing and/or electronically — by Assoc. Prof. Dr. Hamza Yıldız Clinic, as detailed below.

• Data that clearly belongs to an identified or identifiable natural person; processed fully or partially by automated means or by non-automated means as part of a data recording system; including documents such as driver's license, identity card, and passport containing personal identification information such as name-surname, Turkish ID number, nationality, mother's name, father's name, place of birth, date of birth, gender, as well as tax number, social security number, signature information, etc.
• Data that clearly belongs to an identified or identifiable natural person; processed fully or partially by automated means or by non-automated means as part of a data recording system; including phone number, address, email address, fax number, IP address, and similar information.
• Personal data related to records and documents obtained upon entry to a physical space and during the stay within the physical space, that clearly belongs to an identified or identifiable natural person; processed fully or partially by automated means or by non-automated means as part of a data recording system; including camera recordings, fingerprint records, and records taken at security points.
• Data that clearly belongs to an identified or identifiable natural person; photographs and camera recordings (excluding records covered under Physical Space Security Information), data contained in documents that are copies of documents containing personal data.
• Data that clearly belongs to an identified or identifiable natural person; processed fully or partially by automated means or by non-automated means as part of a data recording system; data specified in Article 6 of the Personal Data Protection Law (e.g., health data including blood type, biometric data, etc.)

Having been fully informed about how my personal data specified above will be processed by Assoc. Prof. Dr. Hamza Yıldız Clinic, and how the personal data of myself and my dependents will be processed within the aforementioned scope:

I acknowledge that my personal and special categories of personal data will be processed and transferred to the Republic of Turkey Ministry of Health, institutions and organizations affiliated with the Ministry of Health, private information management systems, and management systems affiliated with the Ministry of Health. I also acknowledge that processing will be carried out for the purposes of creating and tracking appointments, planning and managing healthcare services and their financing, conducting retention and archival activities, tracking requests/complaints, conducting medical diagnosis, treatment, and care services, and providing information to authorized persons, institutions, and organizations.

Data Processing and Transfer Permissions

1. I consent to the processing, retention, transfer, collection, recording, processing, and storage of my personal and special categories of personal data specified above by Assoc. Prof. Dr. Hamza Yıldız Clinic and data processors within the framework of the law.
   [ ] I give consent.      [ ] I do not give consent.
2. I consent to the transfer of my data to your domestic and international suppliers (e.g., certified public accountants and legal consultants, IT service providers) in a manner related to and limited by the services they provide to your clinic.
   [ ] I give consent.      [ ] I do not give consent.
3. I consent to the transfer of my identity information, visual data, and health data to healthcare institutions and organizations located domestically or abroad with which you cooperate for the purpose of obtaining a second opinion regarding the diagnosis and treatment of my health condition.
   [ ] I give consent.      [ ] I do not give consent.
4. I consent to the transfer of my health data to my private insurance company or supplementary insurance companies in provision and billing processes.
   [ ] I give consent.      [ ] I do not give consent.
5. I consent to the processing, storage, and taking of photographs or recordings during the intervention/treatment to be applied to me, along with the personal data shared above, by the physician during the procedure.
   [ ] I give consent.      [ ] I do not give consent.
6. I consent to being informed about appointment and campaign information through means such as email, social media, or SMS to my phone.
   [ ] I give consent.      [ ] I do not give consent.
7. I consent to the transfer of my data, limited to the provision of medical consultation/analysis/testing, to healthcare institutions, doctors, and healthcare personnel located abroad with whom you cooperate for consultation/laboratory services, in the event that I give consent for the consultation/analysis/test.
   [ ] I give consent.      [ ] I do not give consent.

Explicit Consent for Transfer of Special Categories of Personal Data to Patient Family Members and Other Authorized Persons

In compliance with the relevant legislation, primarily Law No. 6698 on the Protection of Personal Data, the Patient Rights Regulation, and the Regulation on Personal Health Data, in addition to cases where transfer is mandatory due to medical necessity or court order, I consent to the transfer of my health data to my family members/relatives, companions, attorneys or legal representatives, and other third parties I authorize as specified below.

[ ] I give consent.      [ ] I do not give consent.

*** I accept, declare, and undertake that I have carried out the relevant transfer in accordance with Law No. 6698 on the Protection of Personal Data and related regulations regarding all personal data, including special categories of personal data, belonging to my family members, relatives, and other third parties that I have shared with your clinic, and that I have informed the relevant persons and, where necessary, obtained their consent.