Name of person described in article or shown in photograph (required)

Subject matter of photograph or article

Title of article

Corresponding author

I [insert full name] give my consent for this information about MYSELF/MY CHILD OR WARD/MY RELATIVE [circle correct description] relating to the subject matter above (“the Information”) to appear in a publication.*

I have seen and read the material to be submitted

I understand the following:

  1. The Information will be published without my name attached and  the course directors will make every attempt 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 text of the article will be edited for style, grammar, consistency, and length
  3. If published in a journal although goes mainly to doctors but is seen by many non-doctors, including journalists.
  4. The Information will also be placed on LAI website, which is usually visited by users each month.
  5. * The Information may also be used in full or in part in publications and products published by same publishers if accepted for publication. This includes publication in English and in translation, in print, in electronic formats, I can revoke my consent at any time before publication, but once the Information has been committed to publication (“gone to press”) it will not be possible to revoke the consent.

Signed

Date