Application Form in Accordance With the Law on the Protection of Personal Data
Date of Application: …….. / …….. /………
☐ “Request for Personal Data” of Oneself
☐ In case of “Request for Personal Data” of another person (if he/she is under the age of 19, his/her parents or guardian, guardian if he/she is under guardianship, the persons to whom the relevant person has expressly given power of attorney in this regard)
- Contact information of the Applicant:
Name and Surname: ……………………………. Signature: ………………………..
Date of Birth: ……………………….. TR ID No: ……………….. Telephone Number: ……………………..
E-mail Address: ……………………………………………………
Address: ………………………………………………………………
- Owner of the Requested Personal Data:
Name & Surname: ……………………. Date of Birth: ……………………….
TR ID No: …………………………… Telephone Number: ………………………..
E-mail Address: …………………………………………………..
Address: ……………………………………………………………..
- Please indicate your relationship with ImpOrth Smile Studio. (Such as the patient, former employee, third party, company employee who provides service to ImpOrth Smile Studio)
Those who receive health services at ImpOrth Smile Studio will fill in it.
☐ Outpatient Treatment ☐ Inpatient Treatment ☐ Surgery ☐ Other
Health Units Received Service:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Those working at ImpOrth Smile Studio will fill in it.
☐ I am an Existing Employee
Former Employee Years of Employment: …………………………………..
Other: …………………..
- Please specify your request under the Personal Data Protection Law in detail:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Please choose the method of notifying you of the response to your application:
☐ I want it to be sent to my address.
☐ I want it sent to my email address.
☐ I want to receive it by hand.
(If requested by proxy, there must be a procuration or a document showing the authority of the authorized person.)
- Description
By filling out this form, you can
- Submit it a signed copy of it to the address
- Mansuroğlu Mh. 288/4 Sk. Avcılar Exclusive Binası Zemin Kat 9E, İzmir / TÜRKİYE
- or send it through a notary public,
- Forward it to the address;
- hello@importhsmilestudio.com
- with a secure electronic or mobile signature via your registered email address or your electronic email address registered in our system.
This application form you have filled out has been organized in order to determine your relationship with ImpOrth Smile Studio, if any, and to respond to your application regarding your personal data processed by ImpOrth Smile Studio in a complete, pointed and accurate manner and within the legal period. In order to eliminate the legal risks that may arise from unlawful and unfair data sharing and especially to ensure the security of your personal data, ImpOrth Smile Studio reserve the right to request additional documents and information (such as a copy of an identity card or driver’s license) for identification and authorization determination.
In the event that the information regarding your requests submitted within the scope of the form is not correct and current or an unauthorized application is made, ImpOrth Smile Studio do not accept any responsibility for the requests arising from such incorrect information or unauthorized application or any problems that may occur during the delivery of our responses to the addresses you specify.
To Be Filled By The Clinic.
Date: ……./……../………
Name & Surname of the Recipient: …………………………. Signature: ……………..
