Patient Consent Form
To record a patient’s consent to publication of information relating to
them or a relative, in a Wiley publication.Name of patient: WAHAB OUEDRAOGO Title of publication/product: Successful management of
traumatic cervical spondyloptosis with incomplete neurological
deficit in a child: A case report Principal author/editor: OUSMANE OUATTARA Principal author/editor’s address: University Hospital
Sourô Sanou, Bobo-Dioulasso, Burkina Faso 01BP 676 Email:
ousman.watt@yahoo.fr _
I, [HAMADO OUEDRAOGO…NAME OF PATIENT / PARENT / GUARDIAN /
RELATIVE***] (the “Licensor”), give my permission to use clinical
information/video/photographic material relating to [WAHAB OUEDRAOGO
(my son)……..NAME AND RELATIONSHIP***] 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 the age of 16, consent should be given by a parent or guardian.I understand that:The information/video/photographic material will be used only in
educational publications intended for health professionals
My name will not be published and Wiley will endeavour to ensure that
I cannot be identified from the clinical information, other than in
relation to 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.
If the publication or product is published on an open access basis, I
understand that it may be accessed freely throughout the world.
This Agreement shall be governed by, and construed in accordance with:
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. In relation to any legal
action or proceedings 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.***SIGNATURE OF PATIENT/PARENT// GUARDIAN / NEXT OF KIN***IF PARENT / GUARDIAN / NEXT OF KIN, STATE RELATIONSHIP TO
PATIENT……FATHER…………………………………….[ADDRESS] SIDERADOUGOU (BURKINA FASO) 00226 67222770[DATE] JANUARY 05, 2024 SIGNATURE OF HEALTH PROFESSIONAL OBTAINING PERMISSION (IF
APPROPRIATE)[ADDRESS] University Hospital Sourô Sanou,
Bobo-Dioulasso, Burkina Faso 01BP 676 Email:
ousman.watt@yahoo.fr [DATE] JANUARY 05, 2024 Note to principal author: The original signed consent form should be
retained by the principal author.
Note to health professional: In addition to the consent form, please
ensure that any other necessary permissions are cleared for use of the
information, including any permissions required for use of information
contained in medical records.