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Consent for Publication of Identifying Material in JAMA Network Journals I give my permission for the following material to appear in the print, online, and licensed versions of JAMA Network Title or subject of article or photograph, video, or audio: I understand that my name will not be published but that complete anonymity cannot be guaranteed. Please check only 1 box below after reading each statement. photographs, illustrations, video, or audio les (if included) in which I am included that will be published. or audio les (if included) in which I am included, but I waive my right to do so. Signed Date Print name If you are granting permission for another person, what is your relationship to that person? JAMA ® JAMA Network Open ™ JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology – Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery JAMA Network Journals This form can be found online at jamanetwork.com/DocumentLibrary/InstructionsForAuthors/PatientConsent.pdf