WikiJournal of Medicine/Ethics statement/Example consent form

I agree that images (or other file format) of my medical condition can be used for scientific publication in an online medical journal. This publication may also include approximate age, sex and relevant current diseases. Otherwise, the publication will limit usage of identifiable information. No name or unique identifier will be mentioned in the publication. Yet, even with the best efforts at keeping confidentiality, anonymity cannot be guaranteed; There is a risk that the information may be identified by someone, somewhere, once the work is published. My medical care will not be affected if I decline to participate. I may revoke the consent at any time. After work publication, removal of my details may not be possible, but consideration should be made to minimize the amount of my details.

Signature: ____________________________________________

Print name : ____________________________________________