Orthodontic Research Study Participation Agreement

Study Information

Study Title: [Insert Study Title] Principal Investigator: [Name], [Credentials] Institution: [Institution Name] Study ID: [Number]

Participant Information

Name: _______________________ Date of Birth: //______ Patient ID: __________________

Purpose and Procedures

I understand that I am being asked to participate in a research study involving orthodontic treatment. By signing this document, I acknowledge the following:

1. Nature of Research

   • The study aims to [insert specific research objective]
   • The duration of participation will be approximately [timeframe]
   • I will be required to [list specific requirements]

2. Required Procedures

   • Regular orthodontic adjustments every [timeframe]
   • Additional imaging studies as needed
   • Completion of questionnaires
   • [Other specific procedures]

Risks and Benefits

Potential Risks:

• Typical orthodontic treatment discomfort
• [List specific study-related risks]
• Time commitment for additional appointments

Potential Benefits:

• Contribution to orthodontic research
• [List specific benefits, if any]
• Standard orthodontic care

Financial Considerations

• Study-related procedures will be provided at [cost details]
• Regular orthodontic treatment costs remain [payment terms]

Confidentiality Statement

All personal and medical information will be kept strictly confidential in accordance with [relevant privacy laws].

Voluntary Participation

I understand that my participation is voluntary and I may withdraw at any time without affecting my regular orthodontic care.

Signatures

Participant Signature: _________________ Date: //______

Parent/Guardian (if applicable): _________________ Date: //______

Investigator Signature: _________________ Date: //______

Contact Information

Principal Investigator: [Name] Phone: [Number] Email: [Address]

IRB Contact: [Information]