Data Subject Application Form

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

This form has been prepared to enable you to submit requests concerning those rights to Private Altınkum Dental Oral and Dental Health Polyclinic (“Altınkum Dental”) in its capacity as data controller.

Application Methods and Contact Channels

You may submit the completed application form to Altınkum Dental by one of the following methods:

Written Application:
You may personally deliver the wet-signed application form to Altınkum Dental’s official correspondence address or send it by post or through a notary public.

Registered Electronic Mail (KEP):
If Altınkum Dental has a registered electronic mail address, you may submit your application through this address.

Secure Electronic Signature or Mobile Signature:
You may sign your application using a secure electronic signature or mobile signature and send it to the relevant electronic communication address of Altınkum Dental.

E-Mail Address Previously Registered in Our Systems:
You may submit your application using an e-mail address that you have previously provided to Altınkum Dental and that is already registered in the Polyclinic’s systems.

IMPORTANT: As a general rule, applications must be submitted by the personal data subject. Where an application is submitted on behalf of another person, documentation proving legal representation or valid authority must be provided. Altınkum Dental may request additional information or documentation that is necessary and proportionate for the purpose of verifying the identity of the applicant.

1. INFORMATION ABOUT THE APPLICANT

Please complete the following fields accurately and in full.

Full Name:
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Turkish Republic Identification Number:
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Passport / Identification Number for Foreign Nationals:
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Residential / Business Address for Notifications:
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Mobile Phone Number:
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E-Mail Address:
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Your Relationship with Altınkum Dental

[ ] Patient
[ ] Patient Relative
[ ] Visitor
[ ] Employee
[ ] Job Applicant
[ ] Supplier / Service Provider
[ ] Other: ...........................................................

Is your relationship with Altınkum Dental still ongoing?

[ ] Yes
[ ] No

If no, approximate date/year when the relationship ended:
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2. SUBJECT OF THE APPLICATION AND YOUR REQUEST

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

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

[ ] If my personal data is being processed, I request information regarding such processing.

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

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

[ ] I request correction of my personal data where it has been processed incompletely or inaccurately.

[ ] I request deletion or destruction of my personal data where the applicable legal conditions 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 an outcome that is detrimental to me where such outcome results solely from the analysis of my personal data through automated systems.

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

[ ] Other:
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Explanation of Your Request

Please describe your request in as much detail as possible and, where applicable, specify the relevant personal data or processing activity:

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3. DOCUMENTS ATTACHED TO THE APPLICATION

If you have any documents that may assist in evaluating your request, please list them below.

Attachment 1:
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Attachment 2:
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Attachment 3:
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Only documents necessary for the evaluation of your request and verification of your identity should be submitted.

4. METHOD FOR RECEIVING THE RESPONSE

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

[ ] By E-Mail
I request that the response be sent to the e-mail address specified in this form and, where required, registered in Altınkum Dental’s systems.

[ ] By Post
I request that the response be sent to the correspondence address specified in this form.

[ ] Personal Collection
I would like to collect the response personally.

If the response is to be collected by an authorised representative, a valid power of attorney or other document demonstrating the representative’s authority may be required.

5. PROCESSING OF APPLICATIONS

Altınkum Dental will evaluate applications submitted under the KVKK according to the nature of the request and will respond as soon as possible and, in any event, within no more than 30 days.

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

If the application is accepted, the necessary action will be taken. If the application is rejected, the grounds for rejection will be communicated to the applicant.

6. DECLARATION OF THE APPLICANT

I request that my application submitted pursuant to the Turkish Personal Data Protection Law No. 6698 be evaluated in accordance with the requests stated above.

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

I acknowledge that the personal data submitted as part of this application may be processed solely for the purposes of receiving and evaluating my application, verifying my identity, responding to my request and completing the relevant application process.

Applicant’s Full Name:
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Application Date:
…… / …… / 2026

Signature:
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