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 
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