Pathology Slide Image Release Agreement

Parties

Name of Releasing Institution or Laboratory:
Representative Name:
Name of Recipient:
Affiliation (if applicable):

Details of Released Material

Type of Pathology Slide Images to be Released:
Case/Patient ID(s):
Date of Image Release:

Terms of Agreement

  • All released pathology slide images are to be used solely for the purpose of:
  • The recipient agrees not to distribute, share, or publish these images outside of the stated purpose without explicit written permission from the releasing institution.
  • All images must be de-identified prior to release in compliance with applicable privacy laws and institutional policies.
  • The recipient agrees to acknowledge the source of the images in all uses, publications, or presentations as:
  • This release does not transfer ownership or copyright of the images.

Signatures

Releasing Institution Representative Signature Date
Recipient Signature Date