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Patient Consent Form

A patient consent form is a paper signed by a patient. This form indicated consent of patient regarding specific action such as acknowledging the risks involved in undertaking certain medical procedures or tests. It is also used to take patients consent about publication of his name or disease in research work. Below is a sample patient consent form for your convenience:

Sample Patient Consent Form

For patients’ consent to publication of material about them in

Clinical and Experimental Dermatology

Type and subject of material (please state intended use)

Clinical Photograph(s)

…………………………………………………………………………………………………

Other patient data (specify)

………………………………………………………………………………………………….

I give my consent for this material to appear in Clinical and Experimental Dermatology. I have seen any photographic material to be published.

I understand the following:

  • The material will be published without my name attached. Every effort will be made to ensure I cannot be identified, but my complete anonymity cannot be guaranteed.
  • The material may be published in the monthly printed edition of Clinical and Experimental Dermatology. Its subscribers and readers are not all dermatologists.
  • If published in the printed edition of Clinical and Experimental Dermatology, the same material will also be used in the electronic edition of the journal. This appears on the world wide web, but is not usually on an open access web site which the general public may see. However, a few sample journal articles are included on an open access website.
  • Photographic material may be used on the cover of the journal. The material will not be used out of context, e.g. for advertising or packaging other products.

I also give consent for the material to be used in other publications (including books, journals, CD-ROMs and online and Internet publications) that may approach Clinical and Experimental Dermatology so long as the material is not used out of context. For example, photographs will not be used in advertising or packaging other products.

Name of patient:_______________________________________________

Signed:______________________________________________________

Date: ______________________________________________________

Name of doctor:_______________________________________________

Signed:_______________________________________________________

Date: ______________________________________________________

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