Informed Patient Consent and Authorization Form
For Sharing of De-Identified Case Report (E-Log / Online Publication)
1. Purpose of Sharing
▢ I understand that healthcare professionals may share my anonymized clinical details, including relevant history, examination findings, radiology or laboratory images, and treatment details, for the purpose of education, discussion, and professional collaboration.
2. Nature of Information and Anonymization
▢ My identifiable personal information (such as name, contact details, address, identification numbers, or facially recognizable images) will not be shared. Only de-identified or anonymized data necessary for the stated purpose will be shared. The health professionals handling my data will comply with the Digital Personal Data Protection Act, 2023, and relevant medical ethics and privacy standards.
3. Risk of Re-identification
▢ I understand that complete anonymity cannot be absolutely guaranteed and that there remains a small possibility that I or my relative may be identified by someone familiar with the case.
4. Scope and Medium of Publication
I understand that my de-identified case report may be immediately shared or published in:
▢ Online academic or professional discussion groups (e.g., WhatsApp, Facebook, blogs, forums)
▢ Printed or online medical journals, educational websites, or institutional repositories and i shall be informed whenever they are published in journals.
▢ Other educational or research platforms, subject to compliance with applicable data protection and professional standards.
5. Rights of the Data Principal (as per DPDP Act, 2023)
I have been informed that:
▢ I have the right to withdraw this consent at any time before publication, by contacting the consent taker in writing or electronically.
▢ I have the right to access, correct, or restrict further sharing of my personal data, if any personal identifiers are inadvertently included.
▢ I can contact the designated Data Protection Officer / Grievance Officer of the institution for any concerns or grievances related to the use of my information.
6. Role of Treating Physician
▢ I understand that the E-log of online discussion on the team-based learning platform (https://pajr.in/) is meant solely for patient and health professional educational collaboration in good faith and not as a substitute for medical advice or treatment from my primary physician, who remains responsible for my clinical care.
I also consent to my data being discussed and used on the platform to identify similar past cases for my benefit and to support future patients with comparable conditions. I understand that the goal of PaJR is to create awareness and collaboration between patients and all other stakeholders in healthcare!
7. Language and Understanding
▢ The purpose and implications of this consent have been explained to me in a language I understand. I have been given an opportunity to ask questions, and all my queries have been satisfactorily answered.
Name of Patient / Legal Guardian / Relative: ___________________________
Signature: ___________________________
Date: ___________________________
Relationship to Patient (if applicable): ___________________________
Name & Designation of Consent Taker: ___________________________
Signature: ___________________________
Date: ___________________________
Anonymized Identifier (if applicable): ___________________________
Institution Address, Mobile No,
Grievance / Data Protection Contact:
Dr Aditya Samitinjay, Physician , Endocrinologist, NHS, UK, CEO, https://pajr.in/, aditya.samitinjay@nhs.net, adityasam93@gmail.com
Dr Sagnika Das,
Lawyer and patient advocate, PaJR volunteer, sagnika.mtb10@gmail.com
Professor Rakesh Biswas, PaJR volunteer, rakesh7biswas@gmail.com
Professor Maruthi Sharma, Epidemiologist and Public health specialist, WA: +91 70138 31179
More about PaJR: https://pajr.in/
Can download the image below for easier signing:
Telugu version:https://
Bengali version: https://userdrivenhealthcare.blogspot.com/2025/11/pajr-bengali-consent-form-dpdp-compliant.html?m=1
Hindi version: https://userdrivenhealthcare.blogspot.com/2025/11/hindi-pajr-consent-form-dpdp-compliant.html?m=1
Conversational citations fully logged here:
[25/03, 11:39]hu2: దశాబ్దాలుగా కాగితం-ఆధారిత ఫార్మాట్లో క్రియాశీలంగా ఉన్న మా DPDP అనుగుణ్య సమ్మతి సేకరణ వర్క్ఫ్లోలో ఈ పెద్ద ఎలక్ట్రానిక్ మైలురాయిని పంచుకోవడానికి సంతోషిస్తున్నాము.
చాలా మందికి రేట్-లిమిటింగ్ దశ ఏమిటంటే, ఈ స్టాటిక్ వెబ్ పేజీ నుండి ఫారమ్ను డౌన్లోడ్ చేసి: (https://userdrivenhealthcare.blogspot.com/2025/10/pajr-consent-form-modified-for-dpdp.html?m=1), ఆపై ప్రింటౌట్ తీసుకుని, పత్రంపై సంతకం చేసి తిరిగి ఇవ్వమని అడగడమే!
ఇక్కడ ఉన్న కొత్త యూజర్ ఇంటర్ఫేస్తో: (https://pajrpublications.gadelab.com/consent-form/), సంతకం చేయడం మరియు సబ్మిట్ క్లిక్ చేయడంతో సహా ప్రతిదీ మీ మొబైల్ ఫోన్లోని యూజర్ ఇంటర్ఫేస్ నుండే చేయవచ్చు. ఇది ఎంతో సులభం!
2. English Transliteration (Read smoothly)
Dashabdaluga kagitam-adharita format-lo kriyashilanga unna ma DPDP anugunya sammati sekarana workflow-lo ee pedda electronic mailurayini panchukovadaniki santhoshistunnamu.
Chala mandiki rate-limiting dasha emitante, ee static web page nundi form-nu download chesi: (https://userdrivenhealthcare.blogspot.com/2025/10/pajr-consent-form-modified-for-dpdp.html?m=1), aapai printout teesukuni, patrampai santakam chesi tirigi ivvamani adagadame!
Ikkada unna kotta user interface-tho: (https://pajrpublications.gadelab.com/consent-form/), santakam cheyadam mariyu submit click cheyadamtho saha pratidi mee mobile phone-loni user interface nunde cheyavacchu. Idi entho sulabham!
3. Word-by-Word Transliteration & Meaning
Sentence 1
| Telugu Word | Transliteration | English Meaning |
| :--- | :--- | :--- |
| దశాబ్దాలుగా | Dashabdaluga | For decades |
| కాగితం-ఆధారిత | Kagitam-adharita | Paper-based |
| ఫార్మాట్లో | Format-lo | In format |
| క్రియాశీలంగా | Kriyashilanga | Active |
| ఉన్న | Unna | Which was |
| మా | Ma | Our |
| DPDP | DPDP | DPDP |
| అనుగుణ్య | Anugunya | Compliant / Following |
| సమ్మతి | Sammati | Consent |
| సేకరణ | Sekarana | Gathering / Taking |
| వర్క్ఫ్లోలో | Workflow-lo | In workflow |
| ఈ | Ee | This |
| పెద్ద | Pedda | Big / Major |
| ఎలక్ట్రానిక్ | Electronic | Electronic |
| మైలురాయిని | Mailurayini | Milestone |
| పంచుకోవడానికి | Panchukovadaniki | To share |
| సంతోషిస్తున్నాము | Santhoshistunnamu | (We are) Glad / Happy |
Sentence 2
| Telugu Word | Transliteration | English Meaning |
| :--- | :--- | :--- |
| చాలా | Chala | Many / Most |
| మందికి | Mandiki | For people |
| రేట్-లిమిటింగ్ | Rate-limiting | Rate-limiting |
| దశ | Dasha | Step |
| ఏమిటంటే | Emitante | Is that / Was when |
| ఈ | Ee | This |
| స్టాటిక్ | Static | Static |
| వెబ్ | Web | Web |
| పేజీ | Page | Page |
| నుండి | Nundi | From |
| ఫారమ్ను | Form-nu | The form |
| డౌన్లోడ్ | Download | Download |
| చేసి | Chesi | Doing (asked to do) |
| ఆపై | Aapai | And then |
| ప్రింటౌట్ | Printout | Printout |
| తీసుకుని | Teesukuni | Taking |
| పత్రంపై | Patrampai | On the document |
| సంతకం | Santakam | Signature |
| చేసి | Chesi | Doing |
| తిరిగి | Tirigi | Return / Back |
| ఇవ్వమని | Ivvamani | To give |
| అడగడమే! | Adagadame! | Asking! |
Sentence 3
| Telugu Word | Transliteration | English Meaning |
| :--- | :--- | :--- |
| ఇక్కడ | Ikkada | Here |
| ఉన్న | Unna | Present / With |
| కొత్త | Kotta | New |
| యూజర్ | User | User |
| ఇంటర్ఫేస్తో | Interface-tho | With interface |
| సంతకం | Santakam | Signature |
| చేయడం | Cheyadam | Doing |
| మరియు | Mariyu | And |
| సబ్మిట్ | Submit | Submit |
| క్లిక్ | Click | Click |
| చేయడంతో | Cheyadamtho | By doing |
| సహా | Saha | Including |
| ప్రతిదీ | Pratidi | Everything |
| మీ | Mee | Your |
| మొబైల్ | Mobile | Mobile |
| ఫోన్లోని | Phone-loni | In phone |
| యూజర్ | User | User |
| ఇంటర్ఫేస్ | Interface | Interface |
| నుండే | Nunde | From itself |
| చేయవచ్చు | Cheyavacchu | Can be done |
| ఇది | Idi | It / This |
| ఎంతో | Entho | So much |
| సులభం! | Sulabham! | Easy! |
Happy to share this major electronic milestone in our DPDP compliant consent taking workflow that was already active in a paper based format for decades.
The rate limiting step for most people was when asked to download the form from a static web page here: https://userdrivenhealthcare.blogspot.com/2025/10/pajr-consent-form-modified-for-dpdp.html?m=1
and then take a printout and sign the document and revert back!
With the new user interface here: https://pajrpublications.gadelab.com/consent-form/, everything can be done from the user interface in your mobile phone itself, including the signature and then click submit.
As simple as that!
[26/03, 02:14]hu1: DPDP Inputs and reviews/comments please
[26/03, 06:02]hu3: Stress of setting up, twin brother 😂😂
[26/03, 06:08]hu3: GPT corrected version
PaJR Health Pvt Ltd
Informed Consent and Authorization for Use of Health Data
(Compliant with Digital Personal Data Protection Act, 2023)
---
1. Identity of the Data Fiduciary
PaJR Health Pvt Ltd ("PaJR Health") is the Data Fiduciary responsible for processing your personal data under this consent.
Contact:
Website: https://pajr.in/
Email: support@pajr.in
---
2. Nature of Personal Data Collected
With your consent, the following categories of data may be collected and processed:
- Clinical information (medical history, diagnosis, treatment details)
- Diagnostic data (laboratory results, radiology images)
- Limited identifiers (age, gender, non-specific location)
Explicitly excluded from sharing unless separately consented:
- Name
- Phone number
- Email address
- Exact address
- Government identifiers
- Facial images or identifiable photographs
---
3. Purpose of Processing (Granular Consent Required)
Please select your preferences:
3.1 Educational Case Discussion (Required for Platform Use)
[ ] I consent to my pseudonymized clinical data being used for discussion among registered healthcare professionals within controlled platforms operated by PaJR Health.
---
3.2 Academic Publication
[ ] I consent to my pseudonymized clinical data being used in medical journals, case reports, or academic publications.
---
3.3 Internal Research and Case Matching
[ ] I consent to my data being used to identify similar cases for clinical learning and improving patient outcomes within PaJR Health systems.
---
3.4 External Platform Sharing (High Risk – Optional)
[ ] I consent to my pseudonymized data being shared on external platforms such as:
- Messaging platforms (e.g., WhatsApp)
- Social media platforms
- Open-access forums
I understand that:
- These platforms operate independently of PaJR Health
- Data shared may be stored outside India
- Complete control over further distribution cannot be guaranteed
---
4. Nature of Data Protection
- Your data will be pseudonymized, meaning direct identifiers will be removed
- However, complete anonymization cannot be guaranteed, and re-identification risk may exist in rare cases
- Appropriate administrative and technical safeguards will be implemented
---
5. Lawful Basis of Processing
Your data is processed solely based on your explicit consent under the Digital Personal Data Protection Act, 2023.
---
6. Data Retention
Your data will be retained:
- For educational and research purposes: up to 10 years
- Or until consent is withdrawn, whichever is earlier
After this, data will be deleted or irreversibly anonymized.
---
7. Your Rights as a Data Principal
You have the right to:
- Access your personal data
- Correct inaccurate data
- Withdraw consent at any time
- Request erasure of your data
- Nominate another person to exercise your rights
---
8. Withdrawal of Consent
You may withdraw your consent at any time, by:
- Email: support@pajr.in
- Platform request (if applicable)
Upon withdrawal:
- No further processing will occur
- Reasonable efforts will be made to delete previously shared data
- Data already published or shared externally may not be fully retractable
---
9. Grievance Redressal
Grievance Officer:
Email: grievance@pajr.in
If unresolved, you may escalate to the Data Protection Board of India under applicable law.
---
10. International Data Transfer
If you consent to external sharing:
- Your data may be transferred and stored outside India
- Such transfers will comply with applicable legal requirements
---
11. Declaration
- I confirm that I have read and understood this document
- I have had the opportunity to ask questions
- I provide my consent voluntarily and without coercion
---
12. Patient Details
Name: _______________________
Age: ________________________
Gender: _____________________
---
13. Consent Record
Date: _______________________
Signature: __________________
---
14. Audit Trail (System Generated)
Submission ID: __________
Timestamp: __________
IP Address: __________
---
[26/03, 06:08]hu3: Overall I think it's good but some nitpicks above courtesy AI.
[26/03, 09:12]hu2: Excellent inputs 👏👏
I have a few Inputs on it before @pajr.in CEO, NHS Endocrinologist can incorporate these in the online form.
@hu3 wish we had this feedback earlier while we redesigned the DPDP compliant form here: https://userdrivenhealthcare.blogspot.com/2025/10/pajr-consent-form-modified-for-dpdp.html?m=1
[26/03, 09:34]hu3: AI is getting better at feedback :-)
[26/03, 10:11]hu2: My feedback on it's feedback:
Instead of
3.3 Internal Research and Case Matching
[ ] I consent to my data being used to identify similar cases for clinical learning and improving patient outcomes within PaJR Health systems.
Let's change the heading and just call it
Case based medical informatics with a link to it's details here: https://pmc.ncbi.nlm.nih.gov/articles/PMC544898/
[26/03, 10:17]hu2: Instead of:
3.2 Academic Publication
[ ] I consent to my pseudonymized clinical data being used in medical journals, case reports, or academic publications.
Let's say:
3.2 Academic Publication
[ ] I consent to my pseudonymized clinical data being used in online medical , patient events data repositories such as https://pajrcasereporter.blogspot.com/?m=1, medical journals such as https://pubmed.ncbi.nlm.nih.gov/40674544/, case reports such as: https://pmc.ncbi.nlm.nih.gov/articles/PMC9685200/, or any other academic publications such as books or book chapters such as: https://www.researchgate.net/publication/394090967_PaJR_as_the_Foundation_for_Next_Generation_Telemedicine
[26/03, 10:23]hu2: Instead of:
3.4 External Platform Sharing (High Risk – Optional)
[ ] I consent to my pseudonymized data being shared on external platforms such as:
- Messaging platforms (e.g., WhatsApp)
- Social media platforms
- Open-access forums
We can say:
3.4 External Platform Sharing
Once your patient's deidentified data is available open access online, it can be shared by online users over any open access forum such as WhatsApp, Facebook and similar social media but the chances of anyone identifying your patient is low
[26/03, 10:25]hu2: Instead of:
6. Data Retention
Your data will be retained:
- For educational and research purposes: up to 10 years
- Or until consent is withdrawn, whichever is earlier
After this, data will be deleted or irreversibly anonymized.
Let's say:
6. Data Retention
Your data will be retained:
- For educational and research purposes for life
[26/03, 15:35]hu1: Please can I give you edit access to the forms directly and you can make the finer edits sir? I'm drowned in a bit of information overload tbh
[26/03, 16:02]hu1: Great inputs here and most valid but my takeaway from this is that the vocal minority always wins, while the silent majority generally does not care. A great example for this is McDonalds chicken is now completely halal because a few people were vocal about it and while the silent majority did not care, McDonalds felt it is better to make all chicken halal and be done with it. In the same way, the design of our consent form is to handle the worst of the worst - either advocate or legal counsel - who can bring down the whole pack of cards and fall our business! While we are protecting ourselves against black swan events, the incentive structure is heavily pivoted in favor of the ruckus creators rather than the normal but silent majority!
[26/03, 16:06]hu4: Very well said. Same with the practice of defensive medicine in today's world.
