Clinical Trial Participant Consent Form

Study Title

Principal Investigator

Institution/Organization

Participant Information

Name:

Date of Birth:

Address:

Contact Number:

Purpose of the Study

Procedures

Risks and Discomforts

Potential Benefits

Confidentiality

Voluntary Participation & Right to Withdraw

Contact Information

Who to contact for questions or in case of injury:

Consent

I have read and understood the information provided above.
I have had the opportunity to ask questions and have received satisfactory answers.
I voluntarily agree to participate in this study.

Participant Signature
Date:

Investigator/Witness Signature
Date: