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1. Patient Information: Patient's personal details including name, age, date of birth, contact information, and medical record number

2. Healthcare Provider Information: Details of the treating physician, healthcare facility, and department involved in the case

3. Case Description: Brief description of the medical case that will be reported, including relevant medical condition or procedure

4. Purpose of Case Report: Explanation of why the case is being reported and how it will contribute to medical knowledge

5. Information Use and Disclosure: Details of how the patient's medical information will be used, what will be published, and who will have access to it

6. Privacy Protection Measures: Description of steps taken to protect patient privacy and confidentiality in accordance with the Data Privacy Act

7. Patient Rights: Outline of the patient's rights regarding the case report, including right to withdraw consent

8. Consent Declaration: Formal statement of consent with space for patient signature and date

9. Healthcare Provider Declaration: Confirmation by healthcare provider that consent has been properly explained and obtained

1. Appendix A: Detailed Case Information: Detailed medical information about the case that will be included in the report

2. Appendix B: Publication Details: Information about where and how the case report will be published

3. Appendix C: Image Schedule: List and copies of specific images/photographs to be included in the case report

4. Appendix D: Privacy Protection Protocol: Detailed description of data protection measures and handling procedures

5. Appendix E: Patient Rights Guide: Comprehensive guide to patient rights regarding medical information and case reports under Philippine law