Informed Consent Statement for Case Reports

I have read the information regarding the preparation of this case report. I understand that the information about me/my child/my ward may be included in a medical case report for publication. I understand that all identifying information will be removed to protect confidentiality as much as possible, but complete anonymity cannot be guaranteed.

I have had the opportunity to ask questions regarding the case report and these have been answered to my satisfaction. I understand that my/my child’s/my ward’s participation is voluntary, and that I can withdraw consent at any time before the report is published.

I understand that my decision regarding participation will not affect my or my child’s/ward’s medical care.

Consent

I hereby give consent for information about myself/my child/my ward to be published in a medical case report.