Consent form
For a patient’s consent to publication of images and/or information about them in the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products.

Name of the patient	
	
Relationship to the patient (in cases when the form is signed by a legal representative of the patient)	
	
Description of the photo, image, text or other information (hereinafter—Information) about the patient (a copy of the Information must be attached to this form)		
Provisional title of the article in which the Information will be included	

	CONSENT

I _______________________________________________________________________, 
(print full name)
give my consent for the Information about me/the patient to appear in the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products.

I confirm that I:
(please tick the boxes to confirm)
□ have seen the photo, image, text or other information about me/the patient;
□ have read the article to be submitted to the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products;
□ am legally entitled to give this consent.

I understand the following:
1) The Information will be published without mentioning my / the patient’s name, however I understand that it is not possible to guarantee complete anonymity. There is a possibility that under some circumstances somebody (for example, somebody who took care of me/the patient, or a relative) may recognise me/the patient.
2) The Information may include details of my/the patient’s medical condition/injury and any current, past, or future prognosis, treatment or surgery.
3) The article is to be published in a journal with global coverage. The Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products is intended for doctors, pharmacists, researchers, and other healthcare professionals, but may also provoke interest of other audiences, e.g. scholars, students, and journalists.
4) The article containing the Information may be included into a press release, be referenced in social media, and/or be used for promotional purposes. Once published, the article will be placed on the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products website and may also be available on other websites.
5) The text of the article will be edited in terms of style, grammar and coherence before publication.
6) I/the patient will not receive any financial benefit from publication of the article.
7) The article may also be used in full or in part in other publications by the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products and/or by other publishers in Russia or abroad (including publications in Russian, publications translated into English, print publications, digital publications, and publications in any other formats that may be used by the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products or other publishers now and in the future). 
8) I can revoke my consent at any time before the article has been approved for publication (“gone to press”) by the Editorial Board of the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products.  
9) This consent form will be retained securely and in confidence by the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products for as long as necessary in accordance with the laws of the Russian Federation. 

Please tick the box to confirm the following:
□ I give consent to the retention of my personal data by the Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products only for the purpose of contacting me in the future, if necessary.

Signature:		
Print full name:		
Address:		
Email:		
Telephone:		

If signing on behalf of the patient, please give the reason why the patient cannot give consent for themselves (e.g. the patient is under 18 or has cognitive or intellectual impairment).
Date: ________________________

If signing on behalf of a family or another group, please tick the box to confirm the following: 
□ All relevant members of the family or group have been informed.

Details of the person who has provided explanations and helped the patient or their representative to sign the form:
(e.g. the corresponding author or another person who has the authority to obtain consent).

Signature:		
Print full name:		
Position:		
Institution:		
Address:		
Email:		
Telephone:		
Date: