ASSENT FORM - PATIENT AGE 7-18 YEARS FOR GENE THERAPY 
ASSENT 
You have neuroblastoma which is not being cured by our usual treatments. We would like 
to treat the disease by helping your body fight it. We will do this by giving you some of your 
own cancer cells which have been altered to help them make you immune to the cancer. 
Before we do this, we will test you for the virus for AIDS. 
If you agree, we will take a small part of your cancer that we have grown, and put a special 
virus into the cancer cells to help them make your immunity work. Then we will inject them 
the cells in two places under your skin. These shots will be one week apart. To see if these 
cells are helping you, after 2 weeks we will "freeze" this small piece of skin and take it out. 
We will also take an extra amount of blood every week for six weeks, and then less often for 
a year. 
SIDE EFFECTS 
Your skin may get red and swollen for 1-3 weeks where the shot went. The chemical the 
cells make may give you a temperature and make you throw up. 
ALTERNATIVE PROCEDURES 
You can have no extra treatment at all, or you can start treatment with drugs or radiation 
straight away, but we believe that this extra treatment may help to cure you more. 
STATEMENT OF UNDERSTANDING 
All information about your treatment will be kept among the hospital staff that needs to 
know. We will not tell anybody else without asking you first. You have the right to ask any 
questions you want and they will be answered. You have had this assent form read or 
discussed with you by your parents and the doctor (Dr. ) caring for you. 
Before you signed this form you had all your questions answered. 
If you have any other questions you can ask your doctor or Dr. Wayne Furman or 
Dr. Malcolm Brenner at any time. 
Patient 
Parent or Guardian 
Physician 
Date and Time 
[772] 
Recombinant DNA Research, Volume 15 
