KVKK-001 · Informed Consent Form
Personal Data — Explicit Consent
Explicit consent for the processing and transfer of health data and e-Nabız integration under KVKK (Turkish Personal Data Protection Law No. 6698)
Dr. Özgür Akşan — Neurosurgery (Brain and Nerve Surgery)
Personal Data — Explicit Consent — full text— Declaration of Explicit Consent. Dear Data Subject / Parent / Guardian / Representative
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What Is a Consent (Informed Consent) Form? What Is It For?
A consent form (formally an informed consent form) is a document that informs you about a procedure or surgery recommended to you. It explains in plain language what the procedure is, its expected benefits, possible risks, and alternative treatments if any.
Its purpose is not to frighten you, but to enable you to make the decision about your health knowingly and willingly. Giving or withholding consent to a procedure is your most natural right.
- It ensures you receive sufficient and understandable information before the procedure.
- It lets you see the benefits and risks in advance and ask your questions.
- It safeguards your right to decide freely and to withdraw your consent at any time.
You can read the form on this page, listen to it, and download it. After reading the form and having your questions answered, you give your consent by signing it at the clinic.
This information was prepared by Dr. Özgür Akşan.
PROCESSING AND PROTECTION OF PERSONAL DATA
Declaration of Explicit Consent
| PATIENT PROTOCOL NO | DATE |
|---|---|
| PATIENT'S FULL NAME | TURKISH ID / PASSPORT NO |
Dear Data Subject / Parent / Guardian / Representative,
Explicit consent means consent that relates to a specific matter, is based on being informed, and is declared of one's free will. Your physician, Dr. Özgür AKŞAN, will hereinafter be referred to in this text as the "Physician" or the "Practice".
Acting in the capacity of "Data Controller", the Physician, as a healthcare service provider — for the performance of agreements concluded with patients/clients and their relatives, in cases expressly provided for by law, for the establishment, exercise or protection of a right, for safeguarding the legitimate interests of the practice and of yourselves, and in cases where this is necessary in order to fully perform the related legal obligations — processes, stores, transfers and, in compliance with the legal conditions, destroys your personal data listed below, your biometric, genetic, health and sexual-life data falling within the scope of Special Categories of Personal Data, as well as your health data obtained through medical imaging such as X-ray, CT, MRI, DEXA, Scintigraphy, Angiography, Ultrasound, etc., within the framework of the Personal Data Protection legislation.
Which of your personal data are processed without obtaining your explicit consent, based on legal grounds arising from the law, is set out in detail for your information in the KVKK (Turkish Personal Data Protection Law No. 6698) Privacy Notice.
We request your explicit consent in respect of the following matters:
Matters of Explicit Consent
1. Processing of General Personal Data. I consent to the processing of my personal data by the Data Controller Physician and the data processors authorised by him, to their storage for the required period, and to their destruction at the end of that period.
2. Processing of Special Categories of Personal Data. I consent to the processing of data concerning health and sexual life, and of biometric and genetic data, to their storage for the required period, and to their destruction at the end of that period.
3. Transfer to Domestic/Foreign Suppliers. I consent to the transfer of my personal data and special categories of personal data to suppliers established in Turkey and abroad (sworn-in certified public accountant, legal counsel, information technology service providers, translation, courier, etc.), limited to and in connection with the services they provide to the practice.
4. Transfer for a Second Opinion. I consent to the transfer of my identity information, my health and sexual-life data and my medical images to domestic/foreign health institutions and organisations and physicians with whom cooperation is established, for the purpose of obtaining a second opinion in the diagnosis and treatment of my health condition.
5. Medical Photographs and Video. I consent to the processing, storage and transfer of the medical photographs and videos to be taken by the Physician in the diagnosis and treatment of my health condition, and to their destruction at the end of the required period.
6. Transfer to Private Insurance Companies / the Social Security Institution (SGK). I consent to the transfer of my health data to my private insurance company, complementary insurance company or authorised intermediary institution in the provisioning and invoicing processes of the healthcare services I receive from the practice.
7. Informational Communication. I consent to being informed by e-mail, post, SMS and telephone regarding the examination/treatment process, in order to provide a better service.
8. e-Nabız Integration. I consent, within the scope of my personal health data, to the processing and storage by the Physician — and, where necessary, the transfer — of all electronic records contained in the e-Nabız system (Turkey's national electronic health record system) (tests, prescriptions, reports, laboratory, radiology, examinations, vaccinations, e-prescriptions, e-reports, e-signed documents, etc.), for the purposes of diagnosis, treatment and healthcare service planning.
General Declaration of Explicit Consent
For the purposes stated above, giving my explicit consent of my own free will; I accept that my personal data to be processed shall be processed, used, transferred, stored for the required period and destroyed at the end of that period, limited to the purposes of processing within the scope of the relevant process; that the necessary information has been provided to me in these matters through the "KVKK Privacy Notice"; and that I have read and understood this text; and I ACCEPT, DECLARE AND UNDERTAKE THAT I APPROVE IT OF MY FREE WILL AND WITH MY INFORMED EXPLICIT CONSENT.
Patient Declaration and Signature
The patient writes the following sentence in their own handwriting and signs:
"I have read and understood. I approve with my explicit consent."
| Full Name | Signature | Date | |
|---|---|---|---|
| Patient | |||
| Legal Representative / Guardian / Proxy <br>(Degree of relationship: ……………………) | |||
| Responsible Physician | Dr. Özgür Akşan |
Rights and Application Information
You may submit your applications and requests concerning your rights in relation to your personal data through the following channels:
- By post / In person: Mimar Sinan Mahallesi, Ziya Gökalp Bulvarı No: 28, Daire 1/2, Alsancak, Konak / İZMİR
- KEP (Registered Electronic Mail): [email protected] (with secure electronic signature, marked "Application/Information Request under KVKK")
- In person: You may request a Data Subject Application Form from the practice staff at the address above.
- Web: You may access the detailed KVKK Privacy Notice at drozguraksan.com/kvkk.
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Disclosure of Health Information to Family Members (Optional)
The section below is to be completed only if you wish to designate a family member or authorised person who may receive information about test results / examinations / appointments / your health condition. If you do not wish to do so, you may leave it blank.
Within the scope of the relevant legislation — except in cases of medical necessity or a court order — I consent of my own free will to the disclosure of my health data (test results, examinations, appointments, health condition, etc.) to the family members / relatives / companions / my proxy / my legal representative whose details I have provided below, and to the other persons I have authorised.
| Degree of Relationship | Full Name | Turkish ID No | Telephone / E-mail |
|---|---|---|---|
I accept, declare and undertake that I have informed the person whose details are shared above and that I have shared their information in accordance with their consent.
| Patient Full Name | Signature | Date |
|---|---|---|
- This form has been prepared based on Nöroşirürjide Aydınlatılmış Rıza Formları [Informed Consent Forms in Neurosurgery] (2025, ISBN 978-605-4149-28-5), published by the Türk Nöroşirürji Derneği (Turkish Neurosurgical Society).