Page:PARAMOUNT Eli Lilly Informed Consent Document.djvu/11

Subject Information and Consent Form

Signature Page

To take part in this study and to allow the use and disclosure of my personal health information for the purposes of the study, I must sign and date this page.

By signing this page, I confirm the following:

• I give permission for my personal health information and study data to be maintained, used and shared as described in this document

• I have read the Subject Information and Consent Form, and have had time to think about whether or not I want to take part in this study.

• All of my questions about the study or this form were answered to my satisfaction. If I did not understand any of the words in this form, the study doctor or a member of the study staff explained them to me.

• I voluntarily agree to allow photographs to be taken of my wound for the study.

• I voluntarily agree to take part in the study, to follow the study procedures, and to provide necessary information to the study doctor or other staff members, as requested.

• I understand that I may freely choose to stop being a part of this study at any time.

• I have received a copy of the Subject Information and Consent Form.

Signature of Subject		Date (ddMMMyy) [Subject must personally date]
Subject's Name (Print or Type)		Subject Number
Signature of Individual Conducting Informed Consent Discussion		Date (ddMMMyy) [Individual conducting informed consent discussion must date]
Name of Individual Conducting Informed Consent Discussion (Print or Type)