Patient Consent for Publication

 

The following information must be provided in order for this form to be processed accurately.

Patients have the right to refuse to sign this consent form; refusal to sign this form will not affect their care in any way.

 

 I hereby give my consent for images or other clinical information relating to my case to be reported in a medical publication.

 

 I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed.

 

 I understand that the material may be published in a journal, Web site or other form of publication. As a result, I understand that the material may be seen by the general public.

 

 I understand that the material may be included in medical books.

 

 

_______________________________                                          ________________________

             Name of the patient                                                             Patient’s date of birth

 

 

_______________________________                                          ________________________

Signature of patient (or signature of the                                                      Date

Person giving consent on behalf of the patient)

 

If you are not the patient, what is your relationship to him or her? (The person giving consent should be a substitute decision maker or legal guardian or should hold power of attorney for the patient).

 

 

_________________________________

Why is the patient not able to give consent? (e.g. is the patient a minor, incapacitated or deceased?)

 

 

_________________________________

If images of the patient’s face or distinctive body markings are to be published, the following section should be signed in addition to the first section:

I give permission for images of my face or distinctive body markings to be published and recognize that I might therefore be identifiable even though my name and initials will not be published.

 

 

________________________________                                      __________________________

Signature of patient (or signature of the                                                           Date

Person giving consent on behalf of the patient)