‫]‪< <^é×ÃÖ]<l^‰]…‚Ö‬‬

‫ﺇﻗﺮﺍﺭ ﻣﻮﺍﻓﻘﺔ ﻣﺮﻳﺾ‬

‫ﺃﻗﺮ ﺃﻧﺎ‬
‫ﺍﻻﺴﻡ‪--------------------------------------------------- -:‬‬
‫ﺍﻝﻨﻭﻉ ‪--------------------------------------------------- -:‬‬
‫ﺍﻝﻌﻤﺭ‪--------------------------------------------------- -:‬‬

‫ﺑﺎﻵﺗﻲ ‪-:‬‬
‫‪ -١‬ﺒﺎﻨﻨﻰ ﺃﻭﺍﻓﻕ ﺃﻥ ﺃﺸﺎﺭﻙ ﻓﻲ ﺒﺤﺙ ﻁﺒﻲ ﺒﻌﻨﻭﺍﻥ ‪----------------------------- -:‬‬
‫‪---------------------------------------------------------‬‬

‫‪ -٢‬ﻭﺃﻨﻨﻲ ﻗﺩ ﺃﺨﺒﺭﺕ ﺒﺄﻥ ﻫﺫﺍ ﺍﻝﺒﺤﺙ ﺒﺤﺙ ﻋﻠﻤﻰ ﻭﺒﺄﺴﺒﺎﺒﻪ ﻭﺃﻥ ﺍﻻﺨﺘﻴﺎﺭ ﺇﺨﺘﻴﺎﺭﻯ‪.‬‬

‫‪ -٣‬ﻭﺃﻨﻨﻲ ﻗﺩ ﺃﺨﺒﺭﺕ ﺒﺎﻝﻔﻭﺍﺌﺩ ﺍﻝﺘﻰ ﺴﺘﻌﻭﺩ ﻋﻠﻰ ﺍﻝﺠﻤﻴﻊ ﻤﻥ ﻨﺘﺎﺌﺞ ﻫﺫﺍ ﺍﻝﺒﺤﺙ ﻭﺃﻥ ﻤﻥ ﺤﻘﻰ ﺍﻻﻨﺴﺤﺎﺏ ﻤﻥ‬
‫ﺍﻝﺒﺤﺙ ﻭﺒﺩﻭﻥ ﺃﻯ ﻤﺴﺌﻭﻝﻴﺔ‪.‬‬

‫‪ -٤‬ﻭﺃﻨﻨﻲ ﻗﺩ ﺃﺨﺒﺭﺕ ﺒﺎﻝﻔﺘﺭﺓ ﺍﻝﺯﻤﻨﻴﺔ ﺍﻝﻤﺘﻭﻗﻊ ﺇﺸﺘﺭﺍﻜﻰ ﻓﻴﻬﺎ ﻓﻲ ﺍﻝﺒﺤﺙ ﻭﺃﻥ ﺍﻝﺒﻴﺎﻨﺎﺕ ﺍﻝﺨﺎﺼﺔ ﺒﺎﻝﺒﺤﺙ‬
‫ﺴﺭﻴﺔ‪.‬‬

‫‪ -٥‬ﻭﺃﻨﻨﻲ ﻗﺩ ﺃﺨﺒﺭﺕ ﺒﺎﻝﺠﻬﺔ ﺍﻝﺘﻰ ﻴﺠﺏ ﺍﻝﺭﺠﻭﻉ ﺇﻝﻴﻬﺎ ﻝﻼﺴﺘﻌﻼﻡ ﻋﻥ ﺃﻯ ﺘﺴﺎﺅﻻﺕ ﺨﺎﺼﺔ ﺒﺎﻝﺒﺤﺙ ﻭﺤﻘﻭﻗﻰ‬
‫ﺇﺫﺍ ﺤﺩﺙ ﻝﻰ ﺃﻯ ﻤﻜﺭﻭﻩ‪.‬‬

‫ﻭﻫﺬﺍ ﺇﻗﺮﺍﺭ ﻣﲎ ﺑﺬﻟﻚ ‪،‬‬

‫ﺘﻭﻗﻴﻊ ﺍﻝﺒﺎﺤﺙ‬ ‫ﺍﻝﻤﻘﺭ ﺒﻤﺎ ﻓﻴﻪ‬

‫‪٢٠١ /‬‬ ‫ﺍﻝﺘﺎﺭﻴﺦ‪/ :‬‬ ‫‪٢٠١ /‬‬ ‫‪/‬‬ ‫ﺍﻝﺘﺎﺭﻴﺦ‪:‬‬

‫ﺍﻝﺭﻗﻡ ﺍﻝﻘﻭﻤﻲ ‪---------- :‬‬

‫ﺭﻗﻡ ﺍﻝﺘﻠﻴﻔﻭﻥ‪----------- :‬‬