4392. 
If you feel that you have a research-related injury, contact Alfred E. Chang, M.D., at 313/936- 
The following numbers are for your use if medical problems develop during treatment: 
Office: 
Clinical Research Center: 
Voice Mailbox: 
Doctor or Nurse: 
313/936-4392 
313-936-8090 
313/936-4392 (after office hours) 
313/936-6267 (This is hospital paging operator. Ask for the 
physician on call for Surgical Oncology). 
Questions on my rights as a patient may be directed to Ann Munro in the Patient/Staff Relations 
Office at 313/763-5456 
I have fully explained to the patient, 
the nature of 
the treatment program described above and such risks involved in its performance. 
\ 
Physician's Signature 
I have been fully informed as to the procedures to be followed including those which are 
investigational, and have been given a description of the attendant discomforts, risk, and benefits to be 
expected, and the appropriate alternative procedures. I realize that since my participation is voluntary, I 
can refuse this treatment without in any way prejudicing my future medical care. In signing this consent 
form, I agree to this method of treatment, and I understand that I will receive the best supportive care even 
if not receiving this protocol treatment. I also understand that my doctors can stop my treatment on this 
protocol if they feel the risks in my case have increased, or to exceed the potential benefits to me. I 
understand, also, that if I have any questions at any time, they will be answered. I have retained a copy of 
this consent form. 
I understand that the University will provide first-aid medical treatment in the unlikely event of 
physical injury resulting from procedures. Treatment of injuries or side effects directly related to 
experimental treatment will be provided in accordance with the University's determination of its 
responsibility to do so. The University does not however, provide compensation to a person who is 
injured while participating as a subject in research. 
i 
Signature of Patient 
Date 
Witness 
11/93 
[ 810 ] 
Recombinant DNA Research, Volume 18 
