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/
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