Explicit Consent Text

Pursuant to the Turkish Personal Data Protection Law No. 6698 (“KVKK”), which entered into force on 07.04.2016, I acknowledge that I have read the Privacy Notice on the Processing of Personal Data provided to me by Specialist Dentist Çağrı Şibal (hereinafter referred to as the “Dental Practice” and/or the “Data Controller”) and that I have been informed about the purposes, methods, and legal grounds on which my personal data are processed.

I have been informed that identity, contact, examination, diagnosis, orthodontic assessment, treatment, radiographic, intraoral imaging, digital scanning, treatment planning, and similar personal data and special categories of personal data necessary for the provision of healthcare services may be processed on the legal grounds provided under the KVKK and applicable healthcare legislation.

This explicit consent form relates only to the following optional data processing activities for which my explicit consent is required, separately from data that may be processed by law or because such processing is necessary for the provision of healthcare services.

1. Additional Data Processing Activities Based on Explicit Consent

I declare that I consent to the personal data processing activities described below, in accordance with the preferences I indicate, where such activities are not strictly necessary for the direct provision of healthcare services by the Dental Practice but require separate explicit consent.

Information and Communications

Apart from communications necessary for my appointments and ongoing treatment process, I consent to receiving information about new services, general information, announcements, and similar communications by telephone, SMS, email, or WhatsApp:

[ ] I consent
[ ] I do not consent

2. Use of Photographs, Videos and Visual Records

I understand that, separately from images required for the clinical provision of treatment and the creation of my patient file, any photographs, videos, intraoral or extraoral images, or similar visual records through which my identity may be identifiable may only be used for educational purposes, scientific presentations, professional information, websites, social media, or similar purposes after I have been separately informed and my separate consent has been obtained.

My general preference regarding such use is:

[ ] I consent
[ ] I do not consent

Note: Where identifiable patient photographs or before-and-after treatment images are to be published, it is more appropriate to use a separate Visual Content Usage Explicit Consent Form specifying the platform and purpose for which the images will be used.

3. International Transfer of Personal Data

Depending on the nature of the orthodontic treatment, digital treatment planning systems, clear aligner manufacturing, orthodontic appliance manufacturing, digital imaging, or related technological services may be provided by service providers located outside Türkiye.

Where personal data must be transferred abroad, the adequacy decision, appropriate safeguards, standard contractual clauses, or other lawful transfer mechanisms provided under Article 9 of the KVKK will first be considered.

Where, exceptionally, the transfer can only be carried out on the basis of my explicit consent, I consent to such transfer after being separately informed about the categories of data to be transferred, the person or organisation to whom the transfer will be made, the relevant country, the purpose of the transfer, and the possible risks:

[ ] I consent
[ ] I do not consent

4. Withdrawal of Explicit Consent

I have been informed that explicit consent must be given freely and that refusing to provide explicit consent will not prevent me from receiving healthcare services that may otherwise be provided under applicable legislation.

I understand that I may withdraw, with prospective effect, at any time any explicit consent I have given in relation to data processing activities carried out on the basis of my consent.

Withdrawal of consent does not, in itself, render unlawful any processing activities that were lawfully carried out before the date of withdrawal.

Explicit Consent Declaration

I acknowledge and declare that I have read the KVKK Privacy Notice provided to me, that I have been informed about the processing of my personal data, and that I have freely determined my preferences regarding the processing activities subject to explicit consent described above.

Full Name: ..................................................................

Turkish Republic Identification No.: .......................................................... (if required)

Date: …… / …… / 2026

Signature: ..................................................................

Data Controller

Specialist Dentist Çağrı Şibal
Orthodontist / Specialist Dentist

Address: Avcılar Exclusive, Mansuroğlu Mah., 288/4. Sk. No: 9/1, A Blok, Office: 39, 35535 Bayraklı / İzmir, Türkiye
Telephone: +90 532 505 40 08
Website: www.cagrisibal.com