Clinical Trial Informed Consent Form

Study Title: Protocol Number: Principal Investigator: Site Address: Phone:

Introduction

Purpose of the Study

Procedures

Risks and Discomforts

Benefits

Confidentiality

Voluntary Participation and Right to Withdraw

Contact Information

Participant Statement

I have read and understood the information provided above. I have had a chance to ask questions and have received answers to my satisfaction. I voluntarily agree to participate in this study.

Participant Name: Signature: Date:

Investigator Name: Signature: Date: