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Data Subject Application Form

You can use this form to submit your requests regarding your rights listed in Article 11 of the Personal Data Protection Law No. 6698 (“Law”) to Dr. Andan Clinic, in its capacity as the data controller, in accordance with Article 13 of the Law and the Communiqué on the Procedures and Principles of Application to the Data Controller.

1. IDENTITY AND CONTACT INFORMATION OF THE APPLICANT

Please fill in the fields below completely so that a healthy response can be provided to your application and identity verification can be performed.

Information TypePlease Declare
Name and Surname 
T.R. ID Number (Passport No for Foreigners) 
Residential / Workplace Address for Notification 
Mobile Phone Number 
E-Mail Address 
Registered E-mail (KEP) Address (If any) 

2. YOUR RELATIONSHIP WITH OUR CLINIC

Please mark the option indicating your relationship with our Clinic and specify the details of the relationship (year, doctor name, department, etc.).

Relationship TypeSelection (X)Relationship Detail / Explanation (e.g., “I had rhinoplasty in 2023”)
Patient / Consultant[ ] 
Former Employee[ ] 
Job Applicant / CV Submitter[ ] 
Supplier / Business Partner Official[ ] 
Visitor[ ] 
Other (Please Specify)[ ] 

3. THE SUBJECT OF YOUR REQUEST UNDER THE LAW

Please specify your request within the scope of Article 11 of the Law by ticking the appropriate box below.

Subject of Request (KVKK Article 11)Selection (X)
1. I want to know whether my personal data is being processed.[ ]
2. If my personal data has been processed, I request information regarding this.[ ]
3. I want to learn the purpose of processing my personal data and whether they are used in accordance with their purpose.[ ]
4. I want to know the third parties to whom my personal data is transferred at home or abroad.[ ]
5. I want my personal data to be corrected if it is processed incompletely or inaccurately.[ ]
6. I want my personal data to be deleted or destroyed.[ ]
7. I request that the correction of incomplete/inaccurate data or the deletion of data be notified to the third parties to whom the data has been transferred.[ ]
8. I object to the emergence of a result against me by analyzing the processed data exclusively through automated systems.[ ]
9. I request compensation for the damage in case I suffer damage due to the unlawful processing of my personal data.[ ]

4. DETAILED EXPLANATION REGARDING YOUR REQUEST

Please state below the details, storyline, or additional explanations regarding your request marked above.

Subject / Explanation:

……………………………………………………………………………………………………………………………………

Attachments: If there are supporting documents for your application (copy of ID card, power of attorney, etc.), please specify: …………………………………………………………………………………

5. METHOD OF NOTIFYING THE RESPONSE TO YOU

Please choose how you would like the response to your application to be delivered to you.

Notification MethodSelection (X)Explanation
I want it sent to my address.[ ]The response will be sent to the address you specified in Section 1.
I want it sent to my e-mail address.[ ]The response will be sent to the e-mail address specified in Section 1. (Fastest method.)
I want to receive it by hand.[ ]The response is delivered in person or to the person authorized by power of attorney against identification.

6. DECLARATION AND SIGNATURE OF THE APPLICANT

In line with my requests stated in this application form, I request that my application to your Clinic be evaluated in accordance with Article 13 of the Law and that I be informed.

  • I accept and declare that the information and documents I have provided to you in this application are correct and up-to-date,

  • That your Clinic may request additional information and documents in order to finalize my application,

  • That my personal data may be processed in order to carry out the necessary examinations.

Applicant Name and Surname: ………………………………………

Application Date: ….. / ….. / 20…..

Signature: ………………………………………

APPLICATION SUBMISSION CHANNELS:

After this form is filled and signed, it must be submitted by one of the following methods:

  1. In-Person Application: A wet-signed copy of the form can be delivered to “Cumhuriyet Mh. Halaskargazi Cd. Selamet Apt, 93/4, D:7 34380 Şişli, İstanbul” along with identity presentation.

  2. Via Notary: The form can be sent as a notification to the above address through a Notary Public.

  3. E-Mail: A scanned wet-signed copy of the form (or signed with Mobile Signature/e-signature) can be sent to info@drandanclinic.com by writing “KVKK Information Request” in the subject line.