I have read and understood the Patient Information Text prepared by Dr. Birgül ALTUNTÜRK within the scope of the Personal Data Protection Law, and I have been informed about the purpose of processing my personal data; the institutions, organizations, companies and third parties to which it is transferred, the methods of collection and the legal grounds related thereto, my rights regarding the protection of my personal data, the security of my personal data and my right to appeal.

Except for cases where my personal and special categories of data are processed and transferred to the extent necessary for the performance of a contract, when explicitly provided for in the law, when it is necessary for Dr. Birgül ALTUNTÜR to fulfill her legal obligations, and for the purposes of protecting public health, preventive medicine, medical diagnosis, treatment and care services, planning and management of health services and their financing, they will be processed and transferred in accordance with the matters stated in the Patient/Service Recipient Information Text within the scope of the Personal Data Protection Law. I ACCEPT, WITH MY EXPLICIT CONSENT, THE PROCESSING, PRESERVATION, ARRANGEMENT, AND TRANSFER OF THIS DATA.

PATIENT/SERVICE RECIPIENT

NAME SURNAME

HANDWRITTEN STATEMENT “I have read and understood”

SIGNATURE, DATE, TIME

PATIENT/SERVICE RECIPIENT RELATIVE (if applicable)

NAME SURNAME

HANDWRITTEN STATEMENT “I have read and understood”

SIGNATURE, DATE, TIME

TRANSLATOR (if required)

NAME SURNAME

DATE, TIME, SIGNATURE