Template 1 Informed Consent to Medical Examination Indicate which examination(s) will be performed (If additional explanation is needed, please include below) Medical Psychological Psychiatric Other (Please Specify) ______________ Prior to an examination, it is necessary that you give your informed consent. By signing this statement, you are confirming that you have been informed of the nature of this examination or evaluation and you freely consent to the examination(s) indicated above. Please review the following points before signing: The purpose and objectives of this examination have been fully explained to me, and I understand that one of the objectives of this examination is to facilitate the investigation and documentation of alleged cases of torture or other ill-treatment for legal purposes. The process of the examination has been explained to me in clear terms which I understand. I understand the benefits and the potential risks or discomforts associated with this examination. I understand that this examination may include related diagnostic tests, sample collections or interviews. I may decline to participate in any of these related procedures without negative consequences. I understand that my participation in this examination is completely voluntary. I may withdraw consent or discontinue participation at any point throughout this procedure. I understand that all information supplied and produced during this examination will form part of my confidential medical record. My confidential data will be stored in a secure location, and I will need to give further consent before any confidential images, recordings, or medical records are shared with third parties for legal proceedings or any other use beyond what is necessary for an effective examination and what is required by law. I have had the opportunity to ask questions about the examination and any questions that I have asked have been answered to my satisfaction. I understand that I have the right to review and inspect my medical records at any time prior to or after consent, and I have the right to receive a copy of my medical records upon request. Forensic Photography: I consent to have photographs taken of me for examination and evaluation purposes. YES NO Audio Recording: I consent to have audio recordings taken for my examination and evaluation purposes. YES NO Name of Patient_______________________ Signature________________ Date_____________ Name of Parent or Guardian (if minor)_________________ Signature___________ Date________ Name of Interpreter_____________________ Signature_________________ Date__________ Name of Examiner_______________________ Signature________________Date___________ 38