Statement of Informed Consent



Template for patient CONSENT FORM

For a patient’s consent to publication of information about them in Arabian Journal of Medical Sciences

Name of person described in article or shown in photograph:__________________________

Subject matter of photograph or article:__________________________

Title of article:_________________________________________________

Medical practitioner or corresponding author:____________________

I_________________________________________ [insert full name] give my consent for this information about MYSELF OR MY CHILD OR WARD/MY RELATIVE [insert full name]:_________________________, relating to the subject matter above (“the Information”) to appear in a journal article, or to be used for the purpose of a thesis or presentation.

I understand the following:

  1. The Information will be published without my name/child’s name/relatives name attached and every attempt will be made to ensure anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody somewhere - perhaps, for example, somebody who looked after me/my child/relative, if I was in hospital, or a relative - may identify me.
  2. The Information may be published in a journal which is read worldwide or an online journal. Journals are aimed mainly at health care professionals but may be seen by many non-doctors, including journalists.
  3. The Information may be placed on a website.
  4. I can withdraw my consent at any time before online publication, but once the Information has been committed to publication it will not be possible to withdraw the consent.

 

Signed:__________________________________ Date: ______________________

 

Signature of requesting medical practitioner/health care worker:

 

_____________________Date:______________