Medical Case Study Republish Permission Form

Case Study Details

Title of Case Study Original Publication Details (Journal Name, Date, Volume, Pages)

Author/Submitter Information

Name Email Affiliation

Republishing Information

Intended Publication/Venue Reason for Request

Permission Agreement

I confirm that I am authorized to request permission to republish the above-mentioned medical case study. I agree to attribute the original source as required and comply with all copyright and ethical guidelines.