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Patient Consent for Publication
This is to state that I authorize the release of my medical information, pictures of radiologic imaging, pathologic slides, and information regarding any eye lesions.
I confirm that I have reviewed all the materials related to myself, and I give my full permission for the publication, reproduction, broadcast and other use of photographs, recordings and other audio-visual material of myself (including of my face) and textual material (case histories) to be reported in a medical publication.
I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed. I give permission for images of my face or distinctive body markings to be published and recognize that I might therefore be identifiable.
I recognize that I have the right to reject or consent to publication of my free will. I understand that I will have no disadvantage in ongoing medical and surgical treatment if I were to reject publication.
| Name of the Patient | Patient’s Date of Birth | ||
| Patient or Legal Guardian Signature | Date | ||
| In case of legal guardian, what is your relationship? _____________________ (Parent/Son/Daughter/Grandchild) | |||
| Why is the patient not able to give consent? ___________________________ (Underage/Deceased/Incapacitated) | |||
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- 1. This Paper hasn’t been published elsewhere and is not being reviewed simultaneously for publication in any other journal.
- 2. I herewith acknowledge that this paper will be reviewed and edited by the Korean Ophthalmological Society and agree that I will transfer the ownership of this paper to the Korean Ophthalmological Society if the paper is published.
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* Position : 1) 교수, Professor 2) 강사, Fellow 3) 의사, Medical doctor 4) 전공의, Resident 5) 수련의, Intern 6) 의대생, Medical student 7) 학생, Student 8) 박사 후 연구원, Post Doc 9) 연구원, Researcher 10) 교사, Teacher 11) 기타, Etc
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