Сonsent form

CONSENT FORM

 

 

Topic of a manuscript or photos: (for Author use only)

Author’s full name who provides a material: (for Author use only)

Address and e-mail: (for Author use only)

 

 

(for Patient or her/his official representative use only):

I give my consent to publish materials with my participation in the Journal of Health Development.

I have seen all figures and read material to be published.

I understand that:

• my name will not be published although I understand that full anonymity cannot be guaranteed;
• material will be published in one of the issues of the Journal;
• material will be available on the Journal’s website and can be read by doctors and other members of the public;
• material can also be used in public bases on medical researches;
• material will not be used for commercial or packaging design;
• material will not be used out of the context.

 

  

Patient’s full name:

Signature:

Date of completion:

 

 

(If you are patient’s official representative please indicate ancestral relationship)

 

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