Clinical Trial Patient Consent Form

Patient Information

Full Name: Date of Birth: Contact Information:

Study Information

Study Title:

Principal Investigator:

Location:

Purpose of the Study:

Procedures

Risks and Benefits

Potential Risks:

Potential Benefits:

Confidentiality

Voluntary Participation

Your participation in this study is voluntary. You may refuse to participate or withdraw at any time without any penalty or loss of benefits to which you are otherwise entitled.

Contact Information

If you have questions about this study or your rights as a participant, please contact:

Participant Consent

Participant Name: Signature: Date: