Patient Consent Form
To record a patient’s consent to the publication of Information relating
to them or a relative in a Wiley publication.
Name of patient: Parnian Hasanzadeh
Title of publication/product: The Ileoileal Intussusception due to a
Tubular Duplication in a Child: A Case Report
Principal author/editor : Khashayar Atqiaee
Principal author/editor’s address: Department of Pediatric Surgery,
Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad,
Iran
(Tel) +985138713801 (Fax) +985138709201
I, [Jamshid Hasanzadeh(parent)] (the ”Licensor”), give my permission to use clinical
information/video/photographic material relating to [MY CHILDParnian Hasanzadeh ] in the publication identified above to be
published by John Wiley & Sons, Inc. or one of its affiliated companies
(”Wiley”), such permission to extend to publication of the Information
by Wiley and its licensees in all media and languages throughout the
world.
***In cases where the patient has died or is incapable of giving
consent, consent may be given by the next of kin. If the patient is
under 16, consent should be provided by a parent or guardian.
I understand that:
The information/video/photographic material will be used only in
educational publications intended for health professionals
(1) My name will not be published, and Wiley will endeavor to ensure
that I cannot be identified from the clinical Information other than
concerning identifiable material (such as videos/photographic material)
for which I give consent. However, I also understand that there is a low
possibility that I may be identified from the clinical Information.
(2) If the publication or product is published on an open-access basis,
I understand that it may be accessed freely worldwide.
This Agreement shall be governed by and construed following 1) the laws
of England and Wales if the Licensor is located outside of the United
States, or 2) the laws of the State of New York if the Licensor is
located in the United States. Concerning any legal action or proceeding
to enforce this Agreement or arising out of or in connection with this
Agreement, each of the parties irrevocably submits to the non-exclusive
jurisdiction of the courts: 1) in England and Wales if the Licensor is
located outside of the United States, or 2) in New York, New York if the
Licensor is located in the United States.