Clinical Research Participation Agreement - Gastroenterology Studies

Gastroenterology Research Study

Study Information

Study Title: [INSERT STUDY NAME] Principal Investigator: [INSERT NAME] Sponsor: [INSERT SPONSOR NAME] Protocol Number: [INSERT NUMBER]

Participant Information

Name: ___________________________ Date of Birth: //____ Medical Record Number: ____________

Agreement Details

1. Voluntary Participation

I understand that my participation in this gastroenterology research study is entirely voluntary. I may withdraw at any time without affecting my medical care.

2. Study Procedures

I agree to participate in the following procedures:

• Clinical examinations
• Blood samples (frequency: _______)
• Endoscopic procedures (if applicable)
• Questionnaires and surveys
• [OTHER PROCEDURES AS APPLICABLE]

3. Risks and Benefits

Potential Risks:

• [LIST STUDY-SPECIFIC RISKS]
• Discomfort during procedures
• Privacy risks

Potential Benefits:

• [LIST STUDY-SPECIFIC BENEFITS]
• Contribution to medical knowledge

4. Confidentiality

I understand that:

• My personal information will be kept confidential
• Data will be coded and stored securely
• Only authorized personnel will have access

5. Compensation

• Study-related medical care costs: [SPECIFY]
• Participation compensation: [SPECIFY AMOUNT/SCHEDULE]

Signatures

Participant Signature: _______________ Date: //____

Investigator Signature: ______________ Date: //____

Witness Signature: _________________ Date: //____