Full Name

Gender

Date of Birth

Contact Phone Number

Email

Emergency contact of the patient. Please state the name and reachable contact phone number.

Emergency Contact

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.

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

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 I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed.

3. I understand that the material may be published in a journal, website 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.