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1. Patient Information: Details of the patient including name, date of birth, patient ID number, and contact information
2. Healthcare Provider Information: Details of the healthcare provider/institution conducting the case report
3. Purpose of the Case Report: Clear explanation of why the case report is being written and its intended use
4. Information to be Used: Specific description of what medical information will be included in the case report
5. Privacy and Confidentiality: Explanation of how personal and medical information will be protected, including anonymization procedures
6. Patient Rights: Clear statement of patient's rights including right to withdraw consent
7. Declaration of Consent: Formal consent statement and signature blocks for patient and healthcare provider
1. Translator Declaration: Required when the patient's primary language is not Dutch, confirming that the form has been explained in their preferred language
2. Legal Representative Authorization: Required when consent is given by a legal representative for minors or incapacitated patients
3. Photography Consent: Required when the case report will include photographs or imaging of the patient
4. Additional Research Use: Optional section for consent to use the case report in future research or educational materials
5. Financial Disclosure: Required when there are any financial implications or compensations involved
1. Information Sheet: Detailed explanation of the case report process and implications in lay terms
2. Data Processing Description: Technical description of how personal data will be processed and protected
3. Withdrawal Form: Form that can be used by the patient to withdraw consent in the future
4. Image Schedule: List and copies of any images or medical illustrations to be included in the case report
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Clinical Research
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Ethics Committee
Publications
Clinical Operations
Regulatory Affairs
Patient Relations
Physician
Clinical Researcher
Medical Director
Research Coordinator
Data Protection Officer
Medical Ethics Officer
Legal Counsel
Privacy Officer
Clinical Trial Manager
Medical Writer
Healthcare Administrator
Research Ethics Committee Member
Medical Publications Manager
Compliance Officer
Medical Affairs Manager
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