Informed Consent Form for Case Study Publication

This consent form is for individuals participating in a case study to be published. Please read the information below carefully and complete the required sections.

1. Case Study Title

2. Investigator(s)/Author(s)

3. Purpose of Publication

4. Description of Information to be Disclosed

5. Consent Statement

I have read and understood the information provided above. I voluntarily consent to the publication of the details of my case in a scientific publication, with the understanding that my identity will remain confidential unless otherwise indicated below.

Do you permit the use of identifying information (e.g., name, image, or other personal identifiers)?

Participant's Name

Signature

Date

Investigator/Author's Name

Signature

Date

Additional Comments (optional)