American Association of Critical-Care Nurses



Consent for Publication of a Case Study Report in Critical Care NurseI give my permission for the {photograph and} information about my medical condition and treatment for a medical journal case report to appear in the print, online, and licensed versions of Critical Care Nurse (CCN) and for CCN to grant permission to third parties to reproduce this material:__________________________________________________________________________________________________________________________________________________I understand that my name will not be published but that complete anonymity cannot be guaranteed. Subject of Case Study:_________________________________________________________________________Author:_________________________________________________________________________Signed (patient)__________________________________Date____________________Print name______________________________________OrSigned (legal authorized representative)___________________________________Date____________________Print name______________________________________If you are granting permission for another person, what is your relationship to that person?____________________________________________ ................
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