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For patient's consent to publication of material about them in the BMJ
Subject of article or photograph:____________________________
BMJ manuscript number___________________
Corresponding author____________________
Date:__________________
I give my consent for this material to appear in the BMJ and associated publications. I have seen and read the material to be published.
I understand the following:
(1) The material will be published without my name attached and every attempt will be made to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody somewhere - perhaps, for example, somebody who looked after me if I was in hospital or a relative - may identify me.
(2) The material may be published in the weekly BMJ, which has a circulation of around 122,000 and goes worldwide. The journal goes mainly to doctors but is seen by many non-doctors, including journalists.
(3) The material will also be placed on the BMJ's website bmj.com which is visited by 1.2 million users each month.
(4) The material may also be used in local editions of the BMJ, which are published in countries like India and China and reach between them some 55,000 doctors worldwide.
(5) The material will not be used for advertising or packaging.
Signed:__________________
I also give consent for the material to be used in other publications that may approach the BMJ so long as the following criteria are met:
(1) The material will not be used for advertising or packaging.
(2) The material will not be used out of context - for example, a picture will not be used to illustrate an article that is unrelated to the subject of the photograph.
Signed:__________________
