ANEXO V
INFORMED CONSENT DECLARATION

If this is case report or if a photograph(s) of a patient(s) is/are involved, this document must accompany your manuscript. Your article cannot be accepted for consideration without it. In the event of any doubt, read the instructions for the submission of articles to the Portuguese Journal of General Practice and Family Medicine (Rev Port Clin Geral 2010;26:325-40). This form only has to be completed by the author handling the correspondence with the journal.

The form should be sent by postal mail to:

Director da Revista Portuguesa de Medicina Geral e Familiar
Av. da Rep├║blica, 97-1┬║
1050-190 Lisboa

Identification
Declaration of informed consent

I, [full name] hereby give my consent to this information on MY PERSON/SON/DAUGHTER OR WARD [indicate correct designation] relating to the matter specified above appearing in the Portuguese Journal of General Practice and Family Medicine (PJGPF), which is published by the Portuguese Association of General Practice and Family Medicine (PAGPF). I have seen and read the material to be submitted to the Journal.

I understand the following:

  1. The information will be published without my name appearing in it and both the PJGPF and the PAGPF will do their utmost to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that someone somewhere or other might identify me (maybe someone who cared for me if I was in hospital or a family member).
  2. The text of the article will be reviewed in terms of style, grammar, coherence and scope.
  3. The information can be published in the PJGPF, which is distributed mainly to physicians but it may also be seen by lay persons.
  4. The information will also be posted on the PJGPF website.
  5. ) The information can also be used, in full or in part, in other publications and products published by the Portuguese Association of General Practice and Family Medicine (PAGPF) or by other publishers to which the PAGPF may license its content. This includes printed publications, publications in electronic format or in any other format that may be used by the PAGPF or its licence holders, now or in the future. In particular the information may appear in local editions of the PJGPF or in other periodicals or foreign publications.
  6. The PAGPF will not allow the use of information in advertising or packaging, or permit its use out of context.
  7. I may withdraw my consent at any time prior to publication, but once the information has been committed for publication it will no longer be possible to withdraw consent.

Place: Date: / /

 

Signature: ________________________________________