Consent Form for Publication in an AME Journal
For a patient’s consent to publish images and/or information about them in AME publications.
Name of patient:
Relationship to person (if the patient not signing this form):
Type and subject of the patient’s materials submitted (e.g., clinical photograph, case descriptions, etc.).
Please state the intended use.
The provisional title of the article in which the material will be included:

As a patient or legal representative, I hereby give my consent for this material to appear in publications owned byAME Publishing Company1. I have seen all the relevant materials that will be published, such as photographs and theirlegends. For case reports, I have read the article.
I fully understand and consent to the following:(1)

The material will be published without my/the patient’s name attached; however, I understand thatcomplete anonymity cannot be guaranteed. It is possible that somebody somewhere - for example, somebody
who looked after me/the patient or a relative - may recognize me/the patient.

(2)

The material may show or include details of my/the patient’s medical condition or injury, and any prognosis,treatment, or surgery that I have/the patient has, had, or may have in the future.

(3)

Under the license which AME uses [Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License (CC BY-NC-ND 4.0)]2, material published in AME journals will be immediately
and permanently free to all to read, download, copy and distribute as defined by the applied license. AME’s
publications go mainly to doctors and other healthcare professionals but also many others, including academics,
students, and journalists.

(4)

The article, including the material, may be the subject of a press release and may be linked to social media and/or used in other promotional activities. Once published, the article will be placed on an AME journal’s website
and may also be available on other websites.

(5)

The text of the article will be edited for style, grammar, and consistency before publication.

(6)

I/the patient will not receive any financial benefit from the publication of the article.

(7)

The article may also be used in full or in part in other publications and products published by AME and/or byother publishers. This includes publication in English and translated, in print, in digital formats, and in any
other formats that may be used by AME or other publishers now and in the future. The article may appear inlocal editions of journals or other publications published in China and overseas.

(8)

If other family members are referenced (e.g., in family history), I also confirm their consent to publication.

(9)

I can revoke my consent at any time before publication, but once the article has been committed to publication(“gone to press”), it will not be possible to revoke the consent.

(10) This consent form will be retained securely and in confidence by AME in accordance with the law for no longer
than necessary.

Signed:Print name:

Address:

Email address:
Telephone no:If signing on behalf of the patient, please give the reason the patient cannot consent for themselves (e.g., thepatient is under 18 or has cognitive or intellectual impairment).
Date:□ If you are signing for a family or another group, please click the box to confirm that all relevant members of thefamily or group have been informed.
If the patient is under the age of 18 but has a sufficient understanding of the consent process and its
implications, they must also confirm their agreement:
Signed:Print name:Date of birth:

Date:

Details of the person who has explained and administered the form to the patient or their representative (e.g., thecorresponding author or another person who has the authority to obtain consent).
Signed:Print name:

Position:

Address:

Institution:

Email address:

Telephone no:Date:

1. AME journals: https://www.amegroups.com/medicine-service
2. CC BY-NC-ND 4.0, see https://creativecommons.org/licenses/by-nc-nd/4.0/