ࡱ> c bjbj |MbMb        8X,d y`xyyyyyy${~t$y pp@$y  9yN!N!N!R  xN!xN!N!nsdU/YqHxOy0yq  ss&  sDN!$y$yr y  B : Case Report Patient Consent Form Participant name: Title of article: Author: Authors department and site: Authors contact number: Associate authors: I freely agree to the use of my de-identified information, images or photographs in the described case report. I have had the opportunity to ask questions and I am satisfied with the answers I have received. The nature, purpose and risks of the case report have been explained to me. I understand the author(s) will make every attempt to ensure my anonymity and that the case report will only include de-identified information/images/photographs. I understand that the case report may be published in academic journals and/or presented at medical conferences. I understand that I may contact the author at any time prior to publication or presentation to withdraw my consent without it affecting my future health care. I understand that the case report will undergo ethical review and obtain approval prior to publication or presentation from Central Adelaide Local Health Network Research Services. I also understand that if I wish to speak to someone not directly involved in the case report about my rights as a participant I may contact CALHN Research Services on 7117 2229. I understand that I will be given a signed copy of this document to keep. 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