You can submit this application form to us, the data controller, Dentist Can Tokman, through the communication channels listed below.

Registered Mail with Return ReceiptAbdi İpekçi Cad. Reasürans Han 2, Nr.: 61, Etage 6, Teşvikiye – Istanbul

IMPORTANT NOTEApplications must be submitted in the name of the individual. Applications cannot be submitted on behalf of a spouse, relative, child, etc. If the clinic suspects the applicant's identity is incorrect, it may request verification information from the individual. Our clinic accepts no responsibility for claims arising from inaccurate or outdated information provided in the form, or from unauthorized applications.

  1. APPLICANT INFORMATION

Please fill in the following information completely:

Name Surname 
Turkish National Identity Number 
Address 
Mobile Phone 
Email Address 
Your Relationship with Our Clinic   ⃝ Visitor   ⃝ Customer    ⃝ Employee    ⃝Other: …
   Job applicant   ⃝ Supplier   ⃝Customer/Supplier Employee 
Has your relationship with our clinic ended? 
  • APPLICANT'S REQUESTS

Please specify your request in detail below, in accordance with the Law on the Protection of Personal Data:

…………… ...

If applicable, please list the documents that support your application:

Appendix 1:……………………………………

Appendix 2:……………………………………

Appendix 3:……………………………………

  • APPLICANT'S STATEMENT

In light of the above-mentioned requirements, I kindly request that your clinic review my application and inform me of the outcome.

I declare and warrant that the documents and information I have provided to you in this application are accurate, up-to-date, and belong to me. I authorize your Clinic to process the information and documents I have provided in this application form solely for the purposes of evaluating and responding to my application, delivering my application to me, and verifying my identity and address.

I would like the application to be answered in one of the ways I have indicated below.

  ⃝I request that the response be sent to the address I provided on my application form.
     ⃝I request that the response to my application form be sent to the email address I provided.Choosing email will allow us to respond to you more quickly..)
     ⃝I want to pick it up in person.If the delivery is made by proxy, a notarized power of attorney or notarized authorization document is required. The recipient's close relatives, such as their spouse or father, are never informed..)

Name and Surname of the Applicant (Data Subject):

Application Date:

Signature: