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:
- 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.
- 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.
- The Information may be placed on a website.
- 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