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Consent Form

  • Contact Information

  • Agreement for Consultation

  • I consent to have the anonymized clinical information from my case used for academic and research purposes. I understand that my right to privacy will be protected by withholding my name and all other identifying information. I also understand that I have the right to withdraw consent to have my information used for academic and research purposes at any time by contacting [email protected]. By consenting, I do not waive any rights to legal recourse in the event of research-related harm (TCPS2-2022, article 3.2 (k). For any questions about the nature and scope of the research, you can contact [email protected].