CONSENT 
Based on the above, I consent to participate in the research and 
have received a copy of the consent form. 
DATE SIGNATURE OF PARTICIPANT 
WITNESS OTHER THAN PHYSICIAN SIGNATURE OF PERSON RESPONSIBLE 
OR INVESTIGATOR AND RELATIONSHIP 
I 
I have discussed this clinical research study with the participant 
and/or his or her authorized representative, using a language which 
is understandable and appropriate. I believe that I have fully 
informed this participant of the nature of this study and its 
possible benefits and risks, and I believe that the participant 
understood this explanation. 
PHYSICIAN/ INVESTIGATOR 
i 
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