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 tests or 
procedures that may be specifically required by this clinical 
research study shall not be my responsibility. I have been 
given the opportunity to discuss the expenses or costs 
associated with my participation in this research activity. 
13. I understand that practicing effective contraception is 
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. 
14 . 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 
[768] 
Recombinant DNA Research, Volume 14 
