USE OF MEDICAL IMAGES (PHOTOGRAPHS / VIDEO)

Declaration of Explicit Consent

PATIENT PROTOCOL NO	DATE
PATIENT'S FULL NAME	TURKISH ID / PASSPORT NO

Dear Data Subject / Parent / Guardian / Representative,

This form is a separate document from the KVKK-001 Declaration of Explicit Consent. Article 5 of KVKK-001 covers the processing of your medical photographs and videos solely for the purposes of diagnosis and treatment. This form concerns uses of your images outside diagnosis and treatment.

You are under no obligation to sign this form. Withholding your consent will in no way affect your examination, diagnosis or treatment, and will not have any adverse effect on your relationship with your physician.

Your physician Dr. Özgür Akşan is referred to in this text as the "Physician".

1. Images Covered by This Consent

Photographs taken during examination
Photographs and videos taken during surgery or intervention
Comparative images from before and after treatment
Radiological images such as X-ray, CT, MRI, angiography
Video recordings containing audio

2. What You Should Know Before Deciding

The following points are of particular importance so that your consent is "based on being informed". Please read them carefully.

An eye bar or facial blurring may not be sufficient to conceal your identity. Distinguishing features such as eyebrows, a moustache, tattoos, scars or body shape may make you recognisable. For this reason, even if an "identity concealed" option is selected, the possibility of recognition is not entirely eliminated.
Content published on the internet may be permanent. Once an image has been published, it may be copied, downloaded or transferred to other platforms by third parties. When you withdraw your consent, the Physician will remove the content from their own accounts; however, the Physician may have no control over content copied by others.
You have the right to see the image before publication. Upon your request, you will be shown before publication which image will be used, where and how.
This form governs only your consent to the processing of your personal data. The restrictions imposed by health legislation on promotional and advertising activities apply separately and independently of your consent.

3. Explicit Consent Options

Please mark the box next to each item for which you give consent with an "X". Each item is a separate consent; marking one does not cover the others. You may also sign the form without marking any of them.

A) MEDICAL EDUCATION IN A CLOSED SETTING

☐ A1. I consent to my images being used in congresses, courses and lectures whose participants are limited to healthcare professionals, with my identity concealed.
☐ A2. I consent to their use in the same settings in a form in which my identity is recognisable.

B) ACADEMIC PUBLICATION

☐ B1. I consent to my images being published in scientific articles, books and conference papers with my identity concealed.
☐ B2. I consent to their publication in the same works in a form in which my identity is recognisable. Under this option, the work concerned will be shown to me before publication.

C) PUBLICLY ACCESSIBLE CHANNELS

☐ C1. I consent to my images being used with my identity concealed in informational content on the Physician's website explaining diseases and treatment processes.
☐ C2. I consent to my images being used with my identity concealed in informational content on the Physician's social media accounts.
☐ C3. I consent to their use on publicly accessible channels in a form in which my identity is recognisable.

Publications under C2 and C3 are made solely on the Physician's official accounts specified below. This consent does not cover the accounts of any other person or institution.

Accounts for which consent is given

4. Duration and Withdrawal of Consent

This consent is valid until withdrawn; the maximum retention period is stated in the Physician's KVKK Privacy Notice.
You may withdraw your consent at any time, without giving any reason.
Upon your withdrawal request, the Physician will remove the images from the channels under their control without delay.
Withdrawal takes effect prospectively; it does not invalidate uses lawfully made before the date of withdrawal.
In printed academic publications, it may not be possible to recall printed copies.

Applications: Mimar Sinan Mahallesi, Ziya Gökalp Bulvarı No: 28, Daire 1/2, Alsancak, Konak / İZMİR — KEP: [email protected]

5. Declaration

I have read and understood the information above. Limited to the items I have marked, I give my approval, of my own free will and with my informed explicit consent, to the use of my medical images for the purposes and on the channels specified. It has been expressly communicated to me that marking none of the items will not affect my treatment process.

The patient writes the following sentence in their own handwriting and signs:

"I have read and understood. I give explicit consent limited to the items I have marked."

	Name – Surname	Signature	Date
Patient
Legal Representative / Guardian / Proxy <br>(Degree of relationship: ……………………)
Responsible Physician	Dr. Özgür Akşan

Notes

Consent is obtained from the patient himself/herself if over 18 years of age; from the patient himself/herself and additionally from his/her legal representative if between 15-18 years of age; and from the legal representative in the case of an unconscious patient, a patient under 15 years of age lacking decision-making capacity, and in medical emergencies.
This form must be printed in two copies, and after both have been signed, one must be given to the patient and the other placed in the patient's file.
This form has been prepared on the basis of the Turkish Personal Data Protection Law No. 6698, Decision No. 2022/630 of the Turkish Personal Data Protection Board, and the ICMJE Recommendations (Protection of Research Participants).