Сonsent form




Topic of a manuscript or photos: (for Author use only)

Author’s full name who provides a material: (for Author use only)

Address and e-mail: (for Author use only)



(for Patient or her/his official representative use only):

I give my consent to publish materials with my participation in the Journal of Health Development.

I have seen all figures and read material to be published.

I understand that:

  • my name will not be published although I understand that full anonymity cannot be guaranteed;
  • material will be published in one of the issues of the Journal;
  • material will be available on the Journal’s website and can be read by doctors and other members of the public;
  • material can also be used in public bases on medical researches;
  • material will not be used for commercial or packaging design;
  • material will not be used out of the context.



Patient’s full name:


Date of completion:



(If you are patient’s official representative please indicate ancestral relationship)