Information Request Form

IN ACCORDANCE WITH THE LAW ON THE PROTECTION OF PERSONAL DATA NO. 6698 INFORMATION REQUEST FORM 1.GENERAL DESCRIPTION

11 Of the Personal Data Protection Law No. 6698.your requests regarding your rights arising from article A of ESTELIT HEALTH SERVICES via this form.Sh. You can forward it to (”ELİT KLİNİK”). These requests will be answered as soon as possible and within thirty days at the latest from the date they reach the ELİT KLİNİK. The answer to your information request will be sent to you in writing or electronically using the communication channels you have selected below.

The information must be filled in completely during the application. Otherwise, your information requests will not be met by the ELİT KLİNİK. In case the information is incorrect or incomplete, ELİT KLİNİK does not accept any responsibility with the bet because the request has not been answered.

Data Controller: ESTELIT HEALTH SERVICES A.Sh.

Adress: Hamidiye, Cendere Cad. No: 103 – 1 T4 Blok, 34396 Kağıthane/İstanbul

Tel: +90 444 0 207

E-mail: [email protected]

2.INFORMATION ABOUT THE RELEVANT PERSON REQUESTING INFORMATION

Name:

Surname:

T.C. ID number / Nationality and passport number:

Phone and Fax number:

E-mail:

Residence or Workplace Address:

Your relationship with our company: Patient-Consultant □ / Business Partner □ / Visitor □ / Other □

3.The SUBJECT OF THE REQUEST (If any, we request that it be included in the relevant information and documents.)

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4.STATEMENT OF THE PERSON CONCERNED

I would like to request that my application be evaluated and answered in accordance with my requests explained above. I accept, declare and undertake that the information I provided during my application is true and up-to-date, belongs to me personally. ESTELIT HEALTH SERVICES A. My personal data and/or personal data of a special nature that I have shared for the information I have requested.Sh. i allow it to be processed by you in connection with its purpose.

☐ I would like to receive the answer to my application by hand in person. (Information about the application is not shared with anyone other than the relevant person who made the application.)

☐ I want the answer to my application to be sent to the e-mail address specified in the Application Form.

☐ I want the answer to my application to be sent to the address indicated on the Application Form. (Please mark the option you have selected.)

Name and Surname of the Relevant Person Who Made the Application:

Application Date:

Signature: Click here to download the form above as a PDF.