Data Controller Application Form

Full Name (Applicant) *

Turkish ID Number (Passport No. for Foreigners) *

Your Relationship with Our Hospital *
Please Select...PatientPatient Relative / Legal RepresentativeEmployeeJob ApplicantVisitorOther

Patient Number / Protocol No (If known)

Application Type *
I am applying on my own behalfI am applying on behalf of someone else (as a Proxy/Legal Representative)

If Applying on Behalf of Someone Else, Please Upload Power of Attorney / Guardianship Decree
(PDF/JPG)

Phone Number *

E-Mail Address

Residential or Workplace Address for Notification *

Your Request under the Personal Data Protection Law *

For the security of my health data, I accept that your hospital may request additional security measures such as SMS verification, e-Nabız verification, or in-person ID presentation while processing my request.