Template 2 Informed Consent for Release of Medical Information Records to be released/Dates: Describe information to be disclosed and dates of service for records released in a manner that specifically identifies the relevant information: _____________________________________________________________________________ _____________________________________________________________________________ Research/Teaching: I consent to have the medical records listed above made available for teaching and research in the healthcare context. I understand that the image may be seen by members of the public, in addition to scientists and medical practitioners in their professional education. All identifying information will be removed and every attempt will be made to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. YES NO Publication: I consent to have the medical records listed above made available for use in medical and scientific journals, textbooks and publications. The material will be published without any identifying information such as my name and every attempt will be made to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. YES NO Other Releases: I consent to have the medical records listed above made available to the following person(s) or category of persons and for the following purposes (describe who will receive information and purpose for disclosure). YES NO __________________________________________________________ The potential risks and benefits of releasing my medical information to the above third parties have been explained to me in terms I understand. I understand that my authorization is voluntary. I may refuse to sign this consent without negatively effecting future treatment or relationship with the person(s) or organisation(s) requesting authorization to release my information. I understand that I may revoke this consent at any time by contacting the person or organisation requesting this authorization. By signing this form or placing my mark in the signature section, I confirm that I have read this consent form or it has been read or translated to me in language I understand. All of my questions related to this release have been answered to my satisfaction. Name of Patient_______________________ Signature________________ Date_____________ Name of Parent or Guardian (if minor)_________________ Signature___________ Date________ Name of Interpreter_____________________ Signature_________________ Date__________ 39