Questions on my rights as a patient may be directed to Ann Munro in 
the Patient/Staff Relations Office at 313/763-5456. 
I have fully explained to the patient, , 
the nature of the treatment program described above and such risks as are 
involved in its performance. 
Physician's Signature 
I have been fully informed as to the procedures to be followed 
including those which are investigational, and have been given a 
description of the attendant discomforts, risk, and benefits to be 
expected, and the appropriate alternative procedures. I realize that, 
since my participation is voluntary, I can refuse this treatment without 
| in any way prejudicing my future medical care. In signing this consent 
form, I agree to this method of treatment, and I understand that I will 
receive the best supportive care even if not receiving this protocol 
treatment. I also understand that my doctors can stop my treatment on 
this protocol if they feel the risks in my case have increased, over time, 
to exceed the potential benefits to me. I understand, also, that if I 
have any questions at any time, they will be answered. I have received a 
copy of this consent form. 
I am not and will not become pregnant during this study. 
I understand that the University will provide first-aid medical 
treatment in the unlikely event of physical injury resulting from research 
procedures. Treatment of injuries or side effects directly related to the 
experimental treatment will be provided at no cost to me. Additional 
medical treatment will be provided in accordance with the University's 
determination of its responsibility to do so. The University does not, 
i however, provide compensation to a person who is injured while 
| participating as a subject in research. 
I have not engaged in any other research projects with the past six 
(6) months [ ] . 
With the past six (6) months, I have been involved in a study by Dr. 
— 
I have [ ] have not [ ] been under the care of a physician within 
the past twelve (12) months. 
Signature of Patient 
Date 
Witness 
Recombinant DNA Research, Volume 15 
[459] 
