Medical Case Report Image Release

I hereby consent to the use of medical images, photographs, and/or videos depicting myself (or my child/ward) for the purpose of publication in a medical journal, presentation, or educational material.

Patient Information

Patient Name Date of Birth Medical Record Number

Representative (if applicable)

Name of Representative Relationship to Patient

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Description

Description of image(s)/material to be released

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I understand that my name will not be published and efforts will be made to conceal my identity, but complete anonymity cannot be guaranteed.

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Signature

Signature Date