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    6 views1 page

    Scan 1

    Uploaded by

    Pawan Jarwal

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    INTERNATIONAL JOURNAL OF INTEGRATED MEDICAL RESEARCH RESEARCH PATIENT CONSENT FORM For Clinical Images) ae j ee + Manuscript Ref. No. &[63]1 Jauss LI6loo0 4 Gocven nal cl Nene PRESENTING AS impel EPZ BUL BAR Carobearns a Tie oe 1A CASE RE : PORT Name of authors: YR» Pawan N- TARWAL, Patient's Registration number: \Y pg Title of manuseri Corresponding author: (With E mai) ; as wR Carppastay93 O-goonast om) To be signed by the patient | hereby give my consent for images and clinical information related o me tobe reported inthe ‘mernaional Journal of Integrated Medical Research (bah in print and cle ediion. | unrstand that myname and identity wl be conceal [orkut Once signed, I cannot revoke my consent Nameofpatien: ARE WAAN JUBEDRHAT ARAR Date of Birth (DD/MM/YY): 1S fo¢| 20/2 Signature of patient (or signature of the person giving consent on behalf of the patient) Relationship (othe patent in case of ther person signing the consent: [ Fay HER Oo Address: C F RQ &

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