Permission for publication of personal information

Please print this form for completion.

Name:…………………………………………………………………………………….

Address:………………………………………………………………………………….

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I understand that Maney Publishing is preparing to publish the following article both in print and electronic format in:

Journal title:        Journal of Orthodontics

Article title:        ……………………………………………………………………………….

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Article authors: ……………………………………………………………………………...

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I hereby give permission for Maney Publishing to publish the following material in this article, in print and electronic format. *Please delete where not applicable.

*details of orthodontic treatment

*clinical photographs of orthodontic treatment

*other (please give details)…………………………………………………………………..

Please describe any personal information and identifiable photographs that are intended for publication:

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For patients signing on their own behalf:

I understand that photographs will not be amended to disguise my identity, but that my name will not be given.

Signed: -------------------------------------------------------------------------------------------------------

Date:    ---------------------------------------

For parents or legal guardians:

I/we understand that photographs will not be amended to disguise the identity of my/our child, but that the name of my/our child will not be given.

Signed: -------------------------------------------------------------------------------------------------------

Date:    ---------------------------------------