CONSENT 
Based upon 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 
OR INVESTIGATOR RESPONSIBLE & 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 the participant understood this explanation. 
PHYSICIAN/INVESTIGATOR 
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