USAFP PATIENT CONSENT FORM
The submitter needs to maintain a copy for their records and be able to produce the document if requested to do so for a patient’s consent to publish personal information about him or her in a clinical case report.
FOR THE CORRESPONDING AUTHOR TO COMPLETE:
Print name of person described in case report or shown in photograph:
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Description of patient material:
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Printed name of person obtaining signature:
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Signed name of person obtaining signature:
_______________________________________________________________________________________
FOR THE PATIENT TO COMPLETE:
I understand the following and give my consent for this information to be published about MYSELF/MY CHILD OR WARD/MY RELATIVE [circle correct description]:
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The information will be published without my name attached and every effort will be made to protect my anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody may identify me, such as relative or a health professional that cared for me.
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If the manuscript is accepted for publication, the information will likely be published both in print and online.
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My personal information will not be used for marketing or advertising purposes. Also, the information should not be taken out of context of the manuscript.
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I may withdraw my consent at any time before publication. However, once the manuscript has been sent to be processed for publication, my consent can no longer be withdrawn.
Signed:
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Date:
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