Patient Consent Form
To record a patient’s consent to publication of information relating to them or a relative, in a Wiley
publication.
Name of patient:__________________________________________________
Title of publication/product:_________________________________________
Principal author/editor:_____________________________________________
Principal author/editor’s address:_________________________________________
____________________________________________________________________
I, [.............................................NAME OF PATIENT / PARENT / GUARDIAN / RELATIVE***] (the “Licensor”), give my permission to use
clinical information/video/photographic material relating to [...............................................................
NAME AND
RELATIONSHIP
***] in the publication identified above to be published by John Wiley & Sons, Inc. or one of its
affiliated companies (“Wiley”), such permission to extend to publication of the information by Wiley and
its licensees in all media and languages throughout the world.
***In cases where the patient has died or is incapable of giving consent, consent may be given by the next
of kin. If the patient is under the age of 16, consent should be given by a parent or guardian.
I understand that:
The information/video/photographic material will be used only in educational
publications intended for health professionals
(1) My name will not be published and Wiley will endeavour to ensure that I cannot be identified
from the clinical information, other than in relation to identifiable material (such as
videos/photographic material) for which I give consent. However I also understand that there is
a low possibility that I may be identified from the clinical information.
(2) If the publication or product is published on an open access basis, I understand that it may be
accessed freely throughout the world.
This Agreement shall be governed by, and construed in accordance with: 1) the laws of England and
Wales, if the Licensor is located outside of the United States, or 2) the laws of the State of New York, if
the Licensor is located in the United States. In relation to any legal action or proceedings to enforce this
Agreement or arising out of or in connection with this Agreement each of the parties irrevocably submits
to the non-exclusive jurisdiction of the courts: 1) in England and Wales, if the Licensor is located outside
of the United States, or 2) in New York, New York, if the Licensor is located in the United States.
***SIGNATURE OF PATIENT/PARENT// GUARDIAN / NEXT OF KIN ...................................................................................
***IF PARENT / GUARDIAN / NEXT OF KIN, STATE RELATIONSHIP TO PATIENT..........................................................
