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    Case Report Consent Form Template

    Uploaded by

    Daniel Antonio Valderrama Merejildo
    This consent form is for a case report on a patient's condition, disease, or experience. The principal investigator and their contact information are provided. The purpose is to share unique information that may help other physicians by publishing or presenting the report. The patient's identity will be kept confidential. There are minimal risks to loss of confidentiality. The patient does not benefit directly but the information may help future patient care. The patient's participation is voluntary and they can withdraw consent before publication, but not after. Any new information will be shared with the patient. The patient signs to authorize their medical record access and participation in the report.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Case Report Consent Form Template

    Uploaded by

    Daniel Antonio Valderrama Merejildo
    505 views2 pages
    This consent form is for a case report on a patient's condition, disease, or experience. The principal investigator and their contact information are provided. The purpose is to share unique information that may help other physicians by publishing or presenting the report. The patient's identity will be kept confidential. There are minimal risks to loss of confidentiality. The patient does not benefit directly but the information may help future patient care. The patient's participation is voluntary and they can withdraw consent before publication, but not after. Any new information will be shared with the patient. The patient signs to authorize their medical record access and participation in the report.

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    case-report-consent-form-template (1).doc

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    This consent form is for a case report on a patient's condition, disease, or experience. The principal investigator and their contact information are provided. The purpose is to share unique information that may help other physicians by publishing or presenting the report. The patient's identity will be kept confidential. There are minimal risks to loss of confidentiality. The patient does not benefit directly but the information may help future patient care. The patient's participation is voluntary and they can withdraw consent before publication, but not after. Any new information will be shared with the patient. The patient signs to authorize their medical record access and participation in the report.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    505 views2 pages

    Case Report Consent Form Template

    Uploaded by

    Daniel Antonio Valderrama Merejildo
    This consent form is for a case report on a patient's condition, disease, or experience. The principal investigator and their contact information are provided. The purpose is to share unique information that may help other physicians by publishing or presenting the report. The patient's identity will be kept confidential. There are minimal risks to loss of confidentiality. The patient does not benefit directly but the information may help future patient care. The patient's participation is voluntary and they can withdraw consent before publication, but not after. Any new information will be shared with the patient. The patient signs to authorize their medical record access and participation in the report.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Consent Form for Case Reports

    This form is best put on clinic letterhead.

    Case Report: Insert TITLE

    Principal Investigator: [Be sure that Principal is not spelled Principle]


    Name, degrees held
    Institution
    Contact Phone Number

    You are being asked to consider allowing Dr. (insert name) to use information
    about your (insert condition/disease/experience) to write what is called a case
    report. Case reports are typically used to share new unique information
    experienced by one patient during his/her clinical care that may be useful for
    other physicians and members of a health care team. A case report may be
    published (in print and/or via internet dissemination) for others to read, and/or
    presented at a conference. This form explains the purpose of this case report.
    Please read this form carefully and take your time to make your decision and ask
    any questions that you may have.

    The purpose of this case report is to inform other physicians that (insert specific
    reason i.e. patients presenting to the ER with X) may be related to Y, however,
    was masked by a common over the counter medication Z).

    Your information being used for this case report includes (insert specific
    information here).

    Dr. (insert name) is obligated to protect your privacy and not disclose your
    personal information (information about you and your health that identifies you as
    an individual e.g. name, date of birth, medical record number). When the case
    report is published or presented, your identity will not be disclosed.

    Although your personal information collected or obtained will be kept confidential


    and protected to the fullest extent of the law, there is a limited risk associated
    with this case report that could result in a loss of confidentiality by virtue of your
    unique experience.

    You will not directly benefit from participating in this case report. The information
    that can be shared with other health care professionals, however, may improve
    the care that is received by others in the future.

    Allowing your information to be used in this case report will not involve any
    additional costs to you. You will not receive any compensation.

    Taking part in this case report is your choice (voluntary). You may choose not to
    take part or you may change your mind at any time. However, once the case
    report is written and published, it will not be possible for you to withdraw it. Your
    decision will not result in any penalty or loss of benefits to which you are entitled
    including the quality of care you receive.

    You will be told about any new information relating to this case report that may
    affect you.

    Your signature below means that you have read the above information about this
    Case Report and have had a chance to ask questions to help you understand
    how your information will be used and that you give permission to allow your
    information to be used in this case report.

    If you have any questions please contact (insert name) at (604) XXX-XXXX ext
    XXX.

    SUBJECT CONSENT TO PARTICIPATE

    Case Report Title:

    Name of Participant: ________________________________________

    Participant/Substitute decision-maker
    By signing this form, I confirm that:
    The case report has been fully explained to me and all of my questions
    have been answered to my satisfaction
    I have been informed of the risks and benefits, if any, of allowing my
    information to be used in this case report
    I have been informed that I do not have to participate in this case
    report
    I have read each page of this form
    I authorize access to my personal health information (medical record)
    as explained in this form
    I have agreed to participate in this case report

    __________________________ _______________________ _____________________


    Name of Participant/Substitute Signature Date
    Decision-maker (print)

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