05 Ağu
CONSENT TEXT
PROF. DR. ÖZTEKİN OTO PATIENT EXPRESS CONSENT TEXT
I accept, declare and undertake that I have read and understood the patient information text prepared by Prof. Dr. Öztekin OTO regarding the Law on the Protection of Personal Data No. 6698 (“PDPL Law”); that I have detailed and complete information about my personal data processed in this way, the purposes for which they are processed, the method and legal reason for obtaining my personal data, the transfer and destruction of my personal data by the Clinic, my rights regarding the processing of my personal data within the scope of the PDP Law and my right to apply to the Clinic regarding this and how I will use this right; that I expressly consent to the issues marked as “I allow” below without being influenced by what is stated in the relevant disclosure text.
I have been informed about the purposes of processing my personal data, the institutions, organizations, companies and healthcare professionals to whom they are transferred, the methods of obtaining and legal reasons, my rights regarding the protection of my personal data, ensuring data security and my right to apply, which are detailed in the Information on the Processing of Personal Data, and that my personal and private data will be processed, transferred and stored in a measured manner by persons or authorized institutions and organizations who are under a confidentiality obligation and who are involved in data processing activities with a confidentiality commitment, in accordance with the matters specified in the Information on the Processing of Personal Data, except for the cases where data processing is mandatory for the execution of the contract and for the purposes of the establishment, use or protection of a right, the protection of public health, preventive medicine, medical diagnosis, treatment and care services, planning and management of health services and their financing, and in a measured manner by persons who are not under a confidentiality obligation and by unauthorized institutions and organizations.
I GIVE EXPRESS CONSENT / I DO NOT GIVE EXPRESS CONSENT.
The Clinic allows me to transfer my personal data and special personal data abroad in accordance with the KVK Law and the information text, in line with the above-mentioned purposes and the relevant sections of the information text.
I GIVE EXPRESS CONSENT / I DO NOT GIVE EXPRESS CONSENT.
I hereby consent to the processing of my personal data by the Clinic in accordance with the KVK Law and the disclosure text, for the purposes specified above, within the scope of carrying out advertising/campaign/promotion processes.
I GIVE EXPRESS CONSENT / I DO NOT GIVE EXPRESS CONSENT.
| CONSENT |
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Write "I understand what I read" in your own handwriting.: …………………………………………………………………… |
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Patient Name Surname:………………………………………………………………... Signature: ………………………………. Date: …./…./…… Hour: …….. |
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Patient Relative Name and Surname: …………………………….………………………….. Signature: ………………………………. Date: …./…./….. Hour: …….. |
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Patient Relative Name and Surname: ………………………………………………………… Signature: ……………………………..... Date: …./…./….. Hour:…….. |
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Reason for Obtaining Consent from the Patient's Relative: The patient is under 19 years of age (Signatures are taken from both parents - mother and father. However, if the family is divorced, the signature is taken from the parent with custody) Not having the power to appeal/not having the ability to make a decision (Signature is obtained from the guardian or legal representative) |
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Unconscious |
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INTERPRETER (If the patient has a language/communication problem) In my opinion, the information I translated was understood by the patient/relative.
Name and Surname of the Translator: ……………………………... Signature: ……………………………….
Date: …./…./….. Hour:….. |
Date: …./…./….. Hour:…..