INFORMED CONSENT FORM

We appreciate your interest in sharing your child's rare case of CUTIS LAXA Syndrome with the medical community. Before
we proceed with publishing this case in online journal, we need to obtain your informed consent.

Please take the time to read this form carefully. If you have any questions or concerns, please do not hesitate to ask. You
may also want to discuss this form with your family or trusted advisors.

The following information is provided to help you make an informed decision about publishing your child's case in online
journals Reports. By signing this form, you are indicating that you have been fully informed about the purpose of the
publication, the potential benefits and risks of publication, and that you freely consent to the publication of your child's
case.

Purpose:

The purpose of publishing your child's case in online journal Reports is to share the unique clinical features, diagnosis,
treatment, and outcome of your child's rare case of CUTIS LAXA Syndrome with the medical community. This publication
can potentially contribute to the advancement of medical knowledge and help other patients with similar conditions.

Potential Benefits:

The potential benefits of publishing your child's case in online journal Reports include:

 Increased awareness and understanding of CUTIS LAXA Syndrome

 Potential contribution to the advancement of medical knowledge
 Potential help to other patients with similar conditions
 Personal satisfaction of sharing your child's story

Potential Risks:

 The potential risks of publishing your child's case in online journals Reports include:
 Loss of privacy, as the case report will be available publicly
 Potential for negative reactions from family members or others in the community
 Potential for unwanted attention from the media or other sources

Confidentiality:

We will take all necessary steps to ensure that your child's case is published without revealing any personally identifiable
information. However, it is important to note that no guarantee can be made that the publication will remain confidential.

Withdrawal:

You have the right to withdraw your consent for publication at any time before the publication is finalized. However, once
the publication is finalized and published, it cannot be withdrawn.

By signing this form, you indicate that you understand the purpose, potential benefits and risks, confidentiality, and your
right to withdraw your consent for publication.

Signature of [Father]: - Sai D M .

Date: 10/4/2023