For a patient’s consent to the publication of Information about them in a journal or thesis
Name of a person described in the article or shown in the photograph:Mahdi Javadpoor
The subject matter of the photograph or article : Figures related to the treatment steps of Mahdi Javadpoor ,
a 36-week male neonate referred to the pediatric surgery service on the second day of life due to Ileal atresia and total Colonic Hirschsprung disease.
Title of article : Ileal Atresia and Total Colonic Hirschsprung Disease in a 36-week Neonate: A Case Report
A medical practitioner or corresponding author: Khashayar Atqiaee
I, Ali Javadpoor , give my consent for this Information about MY CHILD Mahdi Javadpoor relating
to the subject matter above to appear in a journal article or be used for a thesis or presentation.
I understand the following:
  1. The Information will be published without my name/child’s name/relative’s name attached, and every attempt will be made to ensure anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody somewhere - perhaps, for example, somebody who looked after me/my child/relative, if I was in the hospital, or a relative - may identify me.
  2. The Information may be published in a journal that is read worldwide or an online journal. Journals are aimed mainly at healthcare professionals but may be seen by many non-doctors, including journalists.
  3. The Information may be placed on a website.
  4. I can withdraw my consent at any time before online publication, but once the Information has been committed to publication, it will not be possible to withdraw the consent.
Signed: Date 04 /11/2022