PATIENT INFORMED CONSENT FOR CLINICAL RESEARCH 
STATEMENT OF PHYSICIAN OBTAINING INFORMED CONSENT 
I have fully explained this research study to the patient or guardian 
. In my judgment, and the patient's, there was 
sufficient access to information, including risks and benefits, to make an 
informed decision. 
PHYSICIAN 1 S SIGNATURE 
PHYSICIAN'S NAME 
DATE 
PATIENT'S STATEMENT 
I have read the description of the clinical research study or have had 
it translated into language that I understand. I have also discussed it with 
the doctor to my satisfaction. I understand that this study is to determine 
whether or not this treatment is toxic, rather than how effective it is. I, 
, understand that my (patient's) participation is 
voluntary. I know enough about the purpose, methods, risks, and benefits of 
the research study to judge that I (the patient) want to take part in it. 
PATIENT NUMBER 
PATIENT SIGNATURE 
[372] 
Recombinant DNA Research, Volume 18 
