CONSENT TO PARTICIPATE IN THE STUDY 
I have discussed this study with Dr. Hesdorffer to my satisfaction. 
I understand that my participation is voluntary and 
that I can withdraw from the study at any time without prejudice. 
I have read the above and agree to enter this study. Signing this 
form does not waive any of my legal rights. 
I have been informed that if I believe that I have sustained injury 
as a result of participating in this research study, I may contact 
the principal investigator, Dr. Hesdorffer, at 212-305-1738 or the 
Institutional Review Board at 212-305-6950, so that I can review 
the matter and identify the medical resources that are available to 
me . 
I understand that: 
a) The Presbyterian Hospital will furnish any emergency 
medical care determined to be necessary by the medical staff 
of the hospital. 
b) I will be responsible for the cost of such care, either 
personally or through my medical insurance or other form of 
medical coverage. 
c) No monetary compensation for wages lost as a result of 
injury will be paid to me by Columbia Presbyterian Medical 
Center . 
d) I will receive a copy of this consent form. 
Signature: Participant 
Witness 
Investigator 
Date 
The solicitation of subjects into this study has been approved by 
the Columbia Presbyterian Medical Center Institutional Review 
Board . 
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