Case Report Consent Form

A short consent document letting a patient or their representative authorize the use of their clinical details in a case report, recorded with a signature and date.

Use this template

Patient's Name

Nombre

Apellido

Patient's Date of Birth

Date

Patient's Signature

Sign here

If you are not the patient, what is your relationship to him or her?

Why is the patient not able to give consent?

By signing below, I authorize the use of my medical information for research purposes.

Patient's Signature

Sign here

Date

Case Report Consent Form

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