Publication of patient information form

This form must be completed and signed by the patient (s) or the legal representative and kept by the corresponding author.

I _______________________________ [full name] give my consent for the health information, photograph or video presented in the article (in the printed and electronic versions of the Pediatric Emergency Medicine Journal) detailed above about MYSELF/MY CHILD or MY DEPENDANT/MY SPOUSE/MY RELATIVE (Please check as appropriate) to appear in the journal and associated publications (eg, secondary publication). I have seen or read the material (the manuscript, photograph or video file) to be submitted to the journal (or waived my right to do so).

Please check the following box after reading each statement.

I understand that:

❏ My/the patient (s)’s name will not appear anywhere in the manuscript, photograph or video, and the corresponding author will make every effort to ensure my/the patient (s)'s anonymity.

❏ Although complete anonymity cannot be guaranteed, I have discussed this with the corresponding author and agree to its publication.

❏ The text of manuscript might be edited before publication. Once accepted for publication, the manuscript will be published in the journal that is distributed worldwide, and will also be placed on the related websites and social media platforms.

❏ Once accepted for publication, I cannot revoke my consent. To protect my/the patient (s)'s privacy, the corresponding author will keep this form with the relevant photograph or video permanently.

❏ I have the right to refuse. No relevant disadvantage is present in the diagnostic and therapeutic processes.