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1. Interpreter Declaration: Required when the patient's primary language is not English, including interpreter's certification of accurate translation

2. Legal Representative Authority: Required when consent is given by someone other than the patient, detailing their authority to act

3. Additional Use Permission: Optional section for consent to use the information in other contexts (e.g., teaching, further research)

4. Financial Considerations: Required if there are any financial implications or if the patient explicitly waives any financial rights

5. Third Party Information: Required when the case includes relevant information about other individuals (e.g., family members)

1. Schedule 1 - Details of Publication: Specific details about the intended publication(s), including journal names, type of article, etc.

2. Schedule 2 - Information and Materials: Detailed list of all information, images, or other materials covered by the consent

3. Schedule 3 - Privacy Protection Measures: Specific measures that will be taken to protect the patient's privacy

4. Appendix A - Image/Photo Schedule: Copies of specific images/photos that will be published, initialed by the patient

5. Appendix B - Withdrawal Process: Detailed procedure for withdrawing consent, including contact information and limitations