For a patient’s consent to publication of information about them in the BMJ and in associated BMJ Publishing Group Ltd (“BMJ Group”)publications and products. Please note that this form is also available in multiple languages.

Name of person described in article or shown in photograph:__________________________

Subject matter of photograph or article:__________________________

BMJ manuscript number___________________

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 the BMJ and associated publications.*

I have seen and read the material to be submitted to the BMJ

I understand the following:

1. The Information will be published without my name attached and the BMJ 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. The Information may be published in the weekly print BMJ, which is distributed worldwide. The journal goes mainly to doctors but is seen by many non-doctors, including journalists.
4. The Information will also be placed on the BMJ's website, bmj.com, which is usually visited by 1.2 million users each month.
5. * The Information may also be used in full or in part in other publications and products published by the BMJ Group or by other publishers to whom the BMJ Group licenses its content. This includes publication in English and in translation, in print, in electronic formats, and in any other formats that may be used by the BMJ Group or its licensees now and in the future. In particular the Information may appear in local editions of the BMJ or other journals and publications published overseas.
6. The BMJ Group will not allow the Information to be used for advertising or packaging or to be used out of context (for example, a photograph will not be used to illustrate an article that is unrelated to the subject of the photograph.)
7. 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:______________________