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Patient Consent Form for Articles Containing
Patient Details and/or Images
This form provides consent for BMC to publish details and/or images from patients. It must be
completed prior to publication.
Patient/representative details
Patient name: Dian Permata Rizda
If a representative is signing on the patients behalf:
Name of patient representative: __________________________________
Relationship of representative to patient: __________________________________
By signing this form, I confirm that I have the authority to represent the patient and provide
authorization on their behalf.
Article details
Article title: FetalNet: Low Light Fetal Echocardigrphy Enhancement and Dense Convolutional
Network Classifier for Improving Heart Defect Prediction
Journal: BMC Medical Informatics and Decision Making
Declaration by patient or their representative
I, the patient named above or the patients representative, have read the abovenamed article in full
(including text, figures, and supplementary material) and agree to its publication. I am fully aware of
the implications of publication and accept any associated risk. In particular, I understand that,
despite anonymization, it is possible that I (or the patient) may be identified based on the details or
images contained in the article. While the authors and the publisher will make efforts to minimize
this risk, confidentiality cannot be guaranteed.
I understand that the paper will be published online in open access format (using a creative
commons CC BY 4.0 license, http://creativecommons.org/licenses/by/4.0), meaning that it can be
downloaded, copied and reused without limitation. This include any figures, tables, and
supplementary data. The primary audience for the published paper will be healthcare professionals,
research academics and students from across the globe.
The final published version may differ from the one submitted to the journal due to minor revisions,
changes to style, and reformatting. Publication in the journal mentioned above is not guaranteed
and will take place at the discretion of the publisher, and with permission of the Editor-in-Chief (or a
qualified Editorial Board member) after a peer review process.
Signing this form does not remove any of my/the patients statutory rights to privacy. I understand
that I may revoke consent at any point prior to publication, but after publication my consent can no
longer be withdrawn.
I understand that I/the patient will receive no financial benefit or compensation from publication of
the article.
Patient and/or representative signature(s):
Dian Permata Rizda
Place, date:
Palembang, April 14th
2022

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1patient-consent-form.docx

  • 1. Patient Consent Form for Articles Containing Patient Details and/or Images This form provides consent for BMC to publish details and/or images from patients. It must be completed prior to publication. Patient/representative details Patient name: Dian Permata Rizda If a representative is signing on the patients behalf: Name of patient representative: __________________________________ Relationship of representative to patient: __________________________________ By signing this form, I confirm that I have the authority to represent the patient and provide authorization on their behalf. Article details Article title: FetalNet: Low Light Fetal Echocardigrphy Enhancement and Dense Convolutional Network Classifier for Improving Heart Defect Prediction Journal: BMC Medical Informatics and Decision Making Declaration by patient or their representative I, the patient named above or the patients representative, have read the abovenamed article in full (including text, figures, and supplementary material) and agree to its publication. I am fully aware of the implications of publication and accept any associated risk. In particular, I understand that, despite anonymization, it is possible that I (or the patient) may be identified based on the details or images contained in the article. While the authors and the publisher will make efforts to minimize this risk, confidentiality cannot be guaranteed. I understand that the paper will be published online in open access format (using a creative commons CC BY 4.0 license, http://creativecommons.org/licenses/by/4.0), meaning that it can be downloaded, copied and reused without limitation. This include any figures, tables, and supplementary data. The primary audience for the published paper will be healthcare professionals, research academics and students from across the globe.
  • 2. The final published version may differ from the one submitted to the journal due to minor revisions, changes to style, and reformatting. Publication in the journal mentioned above is not guaranteed and will take place at the discretion of the publisher, and with permission of the Editor-in-Chief (or a qualified Editorial Board member) after a peer review process. Signing this form does not remove any of my/the patients statutory rights to privacy. I understand that I may revoke consent at any point prior to publication, but after publication my consent can no longer be withdrawn. I understand that I/the patient will receive no financial benefit or compensation from publication of the article. Patient and/or representative signature(s): Dian Permata Rizda Place, date: Palembang, April 14th 2022