PATIENT INFORMED CONSENT FORM
Tülay Akkol Oral and Dental Health Services Trade Ltd. Co. ("Tülay Akkol Oral Health Clinic / Company") has prepared the patient disclosure text in accordance with Law No. 6698 on the Protection of Personal Data ("KVK Law");
1. Collection, Processing, and Purposes of Your Personal Data
a. Collection of Your Personal Data
Your personal data is collected by our Company pursuant to the KVK Law and related legislation to protect public health, conduct preventive medicine, carry out medical diagnosis, treatment, and care services, plan and manage healthcare services and financing, improve the quality of these services, and fulfill information storage, reporting, and notification obligations required or exempted by public authorities.
Accordingly, your personal data, depending on the type of services provided to you, is collected and processed in all verbal, written, visual, or electronic forms for the purposes outlined below and for Tülay Akkol Oral Health Clinic to fully and properly fulfill its contractual and legal obligations.
Your personal data listed below is obtained and processed based on legal grounds regulated by the KVK Law, Law No. 3359 on Basic Health Services, Decree Law No. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates, Private Companies Regulation, Regulation on Personal Health Data, and regulations of the Ministry of Health and other relevant legislation.
b. Your Processed Personal Data
Within the scope described above, the personal data obtained and processed, including sensitive personal health data, are listed below:
- Your identity information such as full name, Turkish ID number, passport number or temporary ID number (if not a Turkish citizen), ID copy, place and date of birth, photograph,
- Contact information such as address, phone number, email address,
- Financial data such as bank account number, IBAN,
- Medical data obtained during diagnosis, treatment, and care services, including laboratory and imaging results, test results, examination data, prescription information,
- For non-Turkish citizens, nationality data for invoicing purposes by the accounting department,
- For non-Turkish citizens, travel data such as flight information for organizing transportation services by the health tourism and consultation department,
- Your responses and comments shared to evaluate our services,
- CCTV recordings during your visit to our company,
- Voice recordings kept if you contact our company,
- Data regarding private health insurance and Social Security Institution for planning and financing health services,
- Browsing data obtained during website usage, IP address, browser information, and medical documents, surveys, form information, and location data you voluntarily provide.
c. Purpose of Processing Your Personal Data
Your personal and sensitive personal data listed above may be processed by our Company for the following purposes:
- Protection of public health, preventive medicine, medical diagnosis, treatment, and care services, pharmacy, laboratory services,
- Sharing requested information with the Ministry of Health, Social Security Institution, and other public institutions and organizations as required by law,
- Compliance with legal and regulatory obligations,
- Invoicing services for non-Turkish citizens by the accounting department,
- Organizing transportation services for non-Turkish citizens by health tourism and consultation departments,
- Financial management of healthcare services, covering examination, diagnosis, and treatment expenses, sharing requested information with private insurance companies,
- Invoicing by accounting departments for services provided,
- Informing you about your appointment via our Call Center and Digital Channels,
- Verification of identity by Administrative Services, Health Services, and Call Center departments,
- Planning and managing the internal operations of the Company,
- Execution of emergency management processes by the Company,
- Analysis for improving health services by Patient Rights, Quality, and IT departments,
- Risk management and quality improvement by Patient Rights, Quality, and IT departments,
- Training provided to employees by the Quality department,
- Monitoring and preventing misuse and unauthorized activities by IT departments,
- Verification of relationships with institutions partnered with the Company by accounting department,
- Responding to all questions and complaints regarding our health services by Patient Rights and Call Center departments,
- Ensuring all necessary technical and administrative measures for data security of Company systems and applications by Company Management and IT departments,
- Measuring, increasing, and researching patient satisfaction by Patient Rights and Quality departments,
- Implementation of educational activities by educational institutions collaborating with the Company.
Your “Personal and Sensitive Data” mentioned above are stored in physical and electronic archives under appropriate security measures within Tülay Akkol Oral Health Center and external service providers, in strict compliance with regulations.
2. Transfer of Your Personal Data
Your personal data obtained by our Company may be shared with the following institutions, organizations, companies, and healthcare personnel in accordance with Law No. 3359 on Basic Health Services, Decree Law No. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates, KVK Law, Private Companies Regulation, Regulation on Personal Health Data, Ministry of Health regulations, and other relevant legislation, for the purposes described above:
- Ministry of Health, its affiliated units, and family health centers,
- Social Security Institution,
- General Directorate of Security and other law enforcement authorities,
- General Directorate of Population and Citizenship Affairs,
- Ziraat and Halk Bank Employees Pension and Assistance Fund,
- Judicial authorities,
- Private insurance companies (health, retirement, life insurance, etc.),
- Laboratories, medical centers, ambulances, medical device providers, and healthcare institutions cooperating for medical diagnosis and treatment, within Turkey or abroad,
- Healthcare institutions to which the patient is referred or has applied,
- Your authorized legal representatives, Company officials, and shareholders,
- Third-party consultants including lawyers, tax advisors, accountants, and auditors,
- Regulatory and supervisory institutions and official authorities,
- Domestic or international systems, natural or legal persons,
- Your employer,
- Suppliers, support service providers, archive service providers, and business partners benefiting from our services or in cooperation with us (for detailed information, you may apply to our Company in writing).
Accordingly, I declare, state, and undertake that I give my explicit consent in the items marked "
I consent" freely and without any influence.
I have been informed about the purposes, recipients, collection methods, legal grounds, rights regarding protection of personal data, data security, and application rights regarding my personal data as detailed in the Personal Data Processing Disclosure Text.
My
personal and sensitive data will be processed, transferred, and stored only in accordance with the Personal Data Processing Disclosure Text, except when necessary for contractual performance, explicit legal obligation, protection of public health, preventive medicine, medical diagnosis, treatment, and care services, planning and management of healthcare services and financing, and by persons or authorized institutions under confidentiality obligation.
I GIVE / DO NOT GIVE EXPLICIT CONSENT.
CONSENT
Write in your own handwriting: “I have read and understood”: ……………………………………
Patient Name and Surname: …………………………………… Signature: …………………… Date: …./…./…… Time: ……
Relative Name and Surname: …………………………………… Signature: …………………… Date: …./…./…… Time: ……
Relationship: ……………………………………
Relative Name and Surname: …………………………………… Signature: …………………… Date: …./…./…… Time: ……
Relationship: ……………………………………
Reason for obtaining consent from a relative:
• Patient is under 19 years old (signature of both parents required; if parents are divorced, signature from the parent with custody),
• Patient lacks decision-making capacity (signature of legal guardian required),
• Patient is unconscious.
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INTERPRETER (If patient has language/communication issue)
According to the interview, the information I translated has been understood by the patient/relative.
Interpreter Name and Surname: …………………………………… Signature: …………………… Date: …./…./…… Time: ……