Endocrinology Clinical Research Participation Agreement

Study Information

Study Title: [Insert Study Title] Principal Investigator: [Insert Name], MD Study Sponsor: [Insert Sponsor Name] Protocol Number: [Insert Protocol #]

Participant Information

Name: ________________________ Date of Birth: ________________ Medical Record #: _____________

Agreement Terms

1. Voluntary Participation

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

2. Study Procedures

• Regular blood glucose monitoring
• Hormone level testing
• [List specific procedures]
• Follow-up visits every [timeframe]

3. Risks and Benefits

Potential Risks:

• Blood drawing discomfort
• Medication side effects
• [List other risks]

Potential Benefits:

• Access to new treatments
• Regular medical monitoring
• Contribution to medical research

4. Confidentiality

All personal and medical information will be kept confidential according to HIPAA regulations.

5. Compensation

Details of compensation (if any): $_______ Travel reimbursement: $_______

Signatures

Participant Signature: _________________ Date: _______

Investigator Signature: ________________ Date: _______

Witness Signature: ___________________ Date: _______

Contact Information

Study Coordinator: [Name] Phone: [Number] Email: [Email]