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(to be modified as applicable and one signed copy attached with the manuscript)

Manuscript Title:
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work or the analysis and interpretation of the data (when applicable), as well as writing of the anuscript, to take
public responsibility for it and have agreed to have y/our nae listed as a contributor!
I/we believe that the anuscript represents valid work! "either this anuscript nor one with substantially siilar
content under y/our authorship has been published or is being considered for publication elsewhere, e#cept as
described in the covering letter! I/we certify that all the data collected during the study is presented in this anuscript
and no data fro the study has been or will be published separately! I/we attest that, if re$uested by the editors, I/we
will provide the data/inforation or will cooperate fully in obtaining and providing the data/inforation on which the
anuscript is based, for e#aination by the editors or their assignees! %inancial interests, direct or indirect, that e#ist
or ay be perceived to e#ist for individual contributors in connection with the content of this paper have been
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I/(e hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership, including any and all rights
incidental thereto, e#clusively to the )ournal, in the event that such work is published by the )ournal! The )ournal
shall own the work, including
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3. the right to produce preprints or reprints and translate into languages other than +nglish for sale or free
distribution* and
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(e give the rights to the corresponding author to ake necessary changes as per the re$uest of the 'ournal, do the
rest of the correspondence on our behalf and he/she will act as the guarantor for the anuscript on our behalf!
,ll persons who have ade substantial contributions to the work reported in the anuscript, but who are not
contributors, are naed in the ,cknowledgent and have given e/us their written perission to be naed! If I/we
do not include an ,cknowledgent that eans I/we have not received substantial contributions fro non-contributors
and no contributor has been oitted!
"ae &ignature .ate signed
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2 --------------- --------------- --------------- (up to 2 contributors for case report/ iages/ review)
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