Medical Study Publication Release Form
Please complete this form to authorize the publication of your medical study data and to provide necessary information for the publication process.
Full Name
*
First Name
Last Name
Affiliation/Institution
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Role in the Study
*
Please Select
Principal Investigator
Co-Investigator
Corresponding Author
Participant
Other
Study Title
*
Study Reference/ID Number (if applicable)
Type of Publication Requested
*
Journal Article
Conference Abstract
Poster Presentation
Case Report
Other
List of Co-authors (if any)
Do you have any conflicts of interest to declare?
*
No conflicts to declare
Yes, details provided below
If yes, please provide details of conflicts of interest
Signature (Please sign to confirm your consent and release for publication)
*
Submit Release Form
Submit Release Form
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