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Patient Consent for Publication

This is to state that I authorize the release of my medical information, pictures of radiologic imaging, pathologic slides, and information regarding any eye lesions.

I confirm that I have reviewed all the materials related to myself, and I give my full permission for the publication, reproduction, broadcast and other use of photographs, recordings and other audio-visual material of myself (including of my face) and textual material (case histories) to be reported in a medical publication.

I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed. I give permission for images of my face or distinctive body markings to be published and recognize that I might therefore be identifiable.

I recognize that I have the right to reject or consent to publication of my free will. I understand that I will have no disadvantage in ongoing medical and surgical treatment if I were to reject publication.

Name of the Patient Patient’s Date of Birth
Patient or Legal Guardian Signature Date
In case of legal guardian, what is your relationship? _____________________ (Parent/Son/Daughter/Grandchild)

Why is the patient not able to give consent? ___________________________ (Underage/Deceased/Incapacitated)

Name of Corresponding Author Signature of Corresponding Author

Copyright Transfer Form

Title :
Corresponding Author :
Affiliations :
Address :
E-mail :
Tel : Fax :

  • 1. This Paper hasn’t been published elsewhere and is not being reviewed simultaneously for publication in any other journal.
  • 2. I herewith acknowledge that this paper will be reviewed and edited by the Korean Ophthalmological Society and agree that I will transfer the ownership of this paper to the Korean Ophthalmological Society if the paper is published.
Full Name Degree(MD, PhD, etc) Position(Professor, Assistant professor, Student etc ) Signature

Korean Journal of
Ophthalmology

Print ISSN: 1011-8942
Online ISSN: 2092-9382



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