Medical Informed Consent Form

Greetings!

We would like to invite you to take part in this medical research for the study of or a new drug. As part of the research study, we will find out any and all information about the progress of the condition of people having similar conditions like yours.  

Please do understand that taking part in this medical research is purely voluntary and you may reject or turn down this invitation. 

You are being invited because of the condition that you have which affects only one in every ten thousand. We would like to identify the possible origin or cause of this condition and conduct clinical tests to identify the reaction as well as to test whether the solution developed will address and cure the said condition. In this research, we have managed to recruit already 13 participants and we are aiming for 20 individuals to participate in this research program.

The participant shall provide urine samples, saliva, stool, as well as blood samples for our researchers. It may be required to be taken from the participant on a periodical basis until research doctors have a reasonable ground to believe that the collected samples are sufficient.

There may only be a certain level of discomfort upon the drawing of blood from the participant due to pricking, bleeding, or blood extraction. Aside from the extraction of blood samples, there are no other risks involved. 

There are no guaranteed benefits for the participant from participating in this medical research. However, the participant's recovery will definitely help others hope for the recovery of their condition.

No compensation shall be given to the participant. However, no cost shall be incurred from the research and treatment from the participant as well. Costs for clinical care will be shouldered by the participant.

Any and all information that shall be gathered from this research will be kept confidential. The participant also has an option to allow his or her name and other personal information to be disclosed for the further abstract reports.

Proprietary information relating to this research shall be owned by the institution and shall be kept confidential including the identity of the participant.

In case you have questions before participating in this medical research, you may get in touch with:

Name: Dr. John Doe
Email: John@example.com
Phone: 111-222-3333

I hereby give my consent for taking part in this research and treatment.

I have read and understood the information above or it has been read to me. I was given the opportunity and/or I have had the opportunity to ask questions about the program and my questions were answered to my satisfaction and with this, I voluntarily give my consent to the participation in this said program.

I have read out the information sheet to the participant accurately and made sure that the participant understands well the information and procedure that shall be done. The participant asked questions and all of which I answered to the best of my knowledge and to the satisfaction of the participant.