| The consent form should be a separate document from the patient information
sheet and should be on headed paper.
Centre Number:
Study Number:
Patient Identification Number for this trial:
SAMPLE CONSENT FORM FOR RESEARCH STUDY
Title of Project:
Name of Researcher:
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Please tick
to confirm
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I confirm that I have read and understand the information sheet dated ......................... (version ............) for the above study. |
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I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
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I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal rights being affected. |
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I understand that relevant sections of any of my medical notes and data collected during the study, may be looked at by responsible individuals from [company name], from regulatory authorities or from the NHS Trust, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my records.
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I agree to my GP being informed of my participation in the study. |
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I agree to take part in the above research study. |
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__________________________
Name of Patient
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______________
Date
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__________________________
Signature |
__________________________
Name of Person taking consent
(if different from researcher) |
______________
Date
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__________________________
Signature
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__________________________
Researcher |
______________
Date |
__________________________
Signature |
| When complete, 1 copy for patient: 1 copy for researcher site file: 1 (original) to be kept in medical notes. |