11. I have been informed that I should inquire of the attending physician whether or not there 
are any services, investigational agents or devices, and/or medications being offered by 
the sponsor of the clinical research project at a reduced cost or without cost. Should the 
investigational agent become commercially available during the course of the study, I 
understand that I may be required to cover the cost of subsequent doses. 
Costs related to my medical care including expensive drugs, tests or procedures that may 
be specifically required by this clinical research study shall be my responsibility. I have 
been given the opportunity to discuss the expenses or costs associated with my 
participation in this research activity. 
12. I understand that refraining from breast feeding and practicing effective contraception are 
medically necessary and a prerequisite for my participation in this clinical research study. 
Should contraception be interrupted or if there is any suspicion of pregnancy, my 
participation in this clinical research study will be terminated at the sole discretion of the 
investigator. 
13. I may discuss questions or problems during or after this study with Dr. Albert 
Deisseroth at (713) 792-8750. In addition, I may discuss any problems I may have or 
any questions regarding my rights during or after this study with the Chairman of the 
Surveillance Committee at (713) 792-3220 and may in the event any problem arises 
during this clinical research contact the parties named above. 
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 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 
1542] 
Recombinant DNA Research, Volume 19 
