Case Report Consent Form

Case Report Consent Form
Name of the Patient
First NameLast Name
Patient's Date of Birth
DayMonthYear
2 digit day, 2 digit month, 4 digit year1
Date
DayMonthYear
2 digit day, 2 digit month, 4 digit year2
Signature of Patient
Clear
(Or Signature of the Person giving consent on behalf of the patient)
If you are not the patient, what is your relationship to him or her?
(The person giving consent should be a substitute decision maker or legal guardian or should hold power of attorney for the patient).
Why is the patient not able to give consent?
(e.g. is the patient a minor, incapacitated or deceased?)
If images of the patient’s face or distinctive body markings are to be published, the following
section should be signed in addition to the first section:
I give permission for images of my face or distinctive body markings to be published and recognize that I
might therefore be identifiable even though my name and initials will not be published.
Signature of Patient
Clear
(Or Signature of the Person giving consent on behalf of the patient)
Date
DayMonthYear
2 digit day, 2 digit month, 4 digit year3
Should be Empty: