Case Study Consent Form
Reference Number
Case Study Name
Participant Name
First Name Last Name
I, as a participant of the case study specified above, agree with the following statements I selected
I have given enough information about the case and I had the opportunity to ask my questions. I got satisfactory answers for my questions. I am giving my consent to be interviewed by the researcher(s). I am giving my permission to the researcher(s) to access my clinical records if the purpose is to prepare and publish a case study report. The researcher(s) can prepare and publish the case study report. I participate this case voluntarily, I can choose not to participate in part or all of the case study. I also understand that I can withdraw at any stage of the case study without penalty or disadvantage. I understand that my confidentiality may not beguaranteed and there is a possibility that my identity may be discovered by someonereading the case study report. I know that any information I provide to the researcher(s)is confidential, and that no information about me will be disclosed in the report, or to anyother party, without my consent.
Date
Month Day Year
Date
Signature
Clear
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Case Study Consent Form