Information Request Form
INFORMATION REQUEST FORM PURSUANT TO THE LAW NO. 6698 ON THE PROTECTION OF PERSONAL DATA 1.GENERAL DESCRIPTION
No. 6698 You can submit your requests regarding your rights arising from Article 11 of the Personal Data Protection Law No. 11 to ESTELİT SAĞLIK HİZMETLERİ A.Ş. (“ELİT CLINIC”) through this form. Your requests in question will be answered as soon as possible and within thirty days at the latest from the date of receipt by ELİT CLINIC. The answer to your information request will be sent to you in writing or electronically using the communication channels you have selected below.
Information must be filled in completely during the application. Otherwise, your information requests will not be met by ELIT CLINIC. In case the information is incorrect or incomplete, ELIT CLINIC does not accept any responsibility for not responding to the request.
Data Controller: ESTELIT SAĞLIK HİZMETLERİ A.Ş.
Address: Hamidiye, Cendere Cad. No: 103 – 1 T4 Blok, 34396 Kağıthane/İstanbul
Tel: +90 444 0 207
E-mail: [email protected]
2. INFORMATION ON THE RELEVANT PERSON REQUESTING INFORMATION
Name: Surname: Turkish ID number / Nationality and passport number: Telephone and Fax number: E-mail: Residence or Workplace Address: Your relationship with our company: Patient-Consultant □ / Business Partner □ / Visitor □ / Other □
3.SUBJECT OF REQUEST (If any, we kindly request that information and documents related to the subject be attached)
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4. DECLARATION OF THE PERSON CONCERNED
I request that my application be evaluated and responded to me in line with my requests as explained above. I accept, declare and undertake that the information I have provided during my application is real and up-to-date and belongs to me. I allow my personal data and / or sensitive personal data that I have shared for the information I have requested to be processed by ESTELİT SAĞLIK HİZMETLERİ A.Ş. in connection with its purpose.
☐ I would like to receive the answer to my application 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 my e-mail address specified in the Application Form.
☐ I want the answer to my application to be sent to my address specified in the Application Form. (Please mark the option of your choice.)
Name and Surname of the Relevant Person Making the Application:
Application Date:
Signature:
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