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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I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed.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 Agreement 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 Journal of Ophthalmology.
    I hereby grant to Korean Journal of Ophthalmology a non-exclusive license to publish and distribute the article(s) referenced above and any supplemental tables, illustrations or other information submitted therewith that are intended for publication as part of the article in all forms and media (whether now known or hereafter developed), throughout the world, for the full term of copyright, effective when and if the Article is accepted for publication.
Full Name Degree(MD, PhD, etc) Position(Professor, Assistant professor, Student etc ) Signature

Korean Journal of

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

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