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
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: