Bulletin of the History of Medicine
Permission Form, Reprinting Illustrations

Dear xxxxxxx:

I am writing to request permission to reprint the illustration titled "xxxx." It appeared on page xx of (book or journal title), edited by xxxxx, in (year).This illustration is to appear as originally published [or with changes or deletions as noted] in "YOUR ARTICLE’S TITLE," by AUTHOR’S NAME, which the Johns Hopkins University Press is currently preparing for publication. This article is scheduled to be published in the MONTH, YEAR, issue of the Bulletin of the History of Medicine, in a press run of about 1,750 copies.I am requesting nonexclusive world rights to use this illustration in this journal in all languages and for all editions, in print and online, in all retrieval systems now or ever invented. Full acknowledgment will be given in the journal. Please sign below and return one copy of this letter to me to indicate your consent.If you don't hold the copyright to xxxx, or if I must seek permission from another source, please note the fact below. Should it be necessary for me to seek permission elsewhere, any information you could provide to help me contact the proper party would be greatly appreciated.Thank you for your consideration of this request.

Sincerely,------------------------------------------------------------------------

The above request for permission to reprint is approved on the conditions specified below and on the understanding that full credit will be given to the source. The acknowledgment should read as follows:

Approved by:

Date: