Data Subject Application Form

Under the applicable personal data protection legislation, data subjects have certain rights regarding their personal data. You may use this form to submit your requests to Özant Dental Clinic as the data controller.

Application Methods and Contact Channels

You may submit this form through the official communication channels published by the clinic, by written application, notary channel, secure electronic signature/mobile signature or through the e-mail address registered in our systems where applicable.

Important Note: Applications must be made personally by the data subject. Applications on behalf of spouses, relatives, children or third parties cannot be processed unless legal representation/guardianship is duly documented. The clinic may request additional identity verification information if necessary.

1. Applicant Information

Name and Surname: ....................................................................................

Identity / Passport Number: ....................................................................................

Notification Address: ....................................................................................

Mobile Phone: ....................................................................................

E-Mail Address: ....................................................................................

Your Relationship with Our Clinic: [ ] Patient   [ ] Visitor   [ ] Employee / Candidate   [ ] Supplier   [ ] Other: ............

2. Request Details

Please describe your request regarding your personal data in detail:

{.....................................................................................................................}

{.....................................................................................................................}

Supporting documents, if any:

Attachment 1: ....................................................................................................

Attachment 2: ....................................................................................................

3. Preferred Response Method

[   ] By E-Mail: I request the response to be sent to the e-mail address stated above.

[   ] By Post: I request the response to be sent to my physical address.

[   ] In Person: I request to receive the response in person. If received by proxy, a notarized power of attorney must be presented.

4. Applicant Declaration and Signature

I request that my application be evaluated and answered within the legal period. I declare that the information and documents provided in this application are accurate, up to date and belong to me.

Applicant Name and Surname:

Application Date:

Signature: