Revised 8-26-94 
PHYSICIAN’S STATEMENT 
I have offered an opportunity for further explanation of this procedure to the individual 
whose signature appears above. The protocol which he/she will be participating in is "Evalu- 
ation of Repeat Administration of a Replication Deficient, Recombinant Adenovirus Vector 
Containing the Normal Cystic Fibrosis Transmembrane Conductance Regulator cDNA to the 
Airways of Individuals with Cystic Fibrosis" 
M.D. 
Note: The subject must be given a copy of this consent form. A signed copy must 
be filed in the subject’s medical record in the Records Department. 
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