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The Patient Consent Form For Case Report is a critical document used in Malaysian healthcare settings when medical professionals wish to publish or present interesting or unique patient cases for educational or scientific purposes. This document becomes necessary when healthcare providers identify cases that contribute significant value to medical knowledge and wish to share them with the broader medical community. The form ensures compliance with Malaysian healthcare regulations, including the Personal Data Protection Act 2010 and Medical Act 1971, while also adhering to international medical publication standards. It provides a structured approach to obtaining informed consent from patients, clearly outlining how their medical information will be used, protecting their privacy rights, and detailing the scope of permission granted for case publication. The document is essential for maintaining ethical standards in medical research and publication while protecting both healthcare providers and patients.

1. Patient Information: Patient's personal details including name, IC number/passport, age, and contact information

2. Healthcare Provider Information: Details of the healthcare facility and treating physician(s)

3. Case Description: Brief description of the medical case that will be reported, including condition and treatment

4. Purpose and Nature of Case Report: Explanation of why the case is being reported and how the information will be used

5. Scope of Consent: Detailed description of what the patient is consenting to, including use of medical information and images

6. Privacy and Confidentiality: Information about how patient privacy will be protected and data handled

7. Publication Details: Information about where and how the case report may be published or presented

8. Declaration and Signatures: Formal declaration of consent and signature blocks for patient/guardian and healthcare provider