Periodontal Research Study Participation Agreement

Study Information

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

Participant Information

Name: ________________________________ Date of Birth: _________________________ Contact Number: _______________________

Purpose of Research

I understand that I am being asked to participate in a research study investigating [brief description of study purpose]. This study aims to [specific goals].

Study Procedures

1. Initial examination and periodontal assessment
2. [Detail specific procedures]
3. Follow-up visits at [specify intervals]
4. Collection of [specify samples/data]

Risks and Benefits

Potential Risks:

• Minor discomfort during examination
• [List other potential risks]
• [Additional risk factors]

Potential Benefits:

• Access to advanced periodontal care
• Contribution to dental research
• [Other benefits]

Confidentiality Statement

All personal information and research data will be:

• Coded and de-identified
• Stored securely
• Accessible only to authorized research personnel

Voluntary Participation

I understand that:

• My participation is entirely voluntary
• I may withdraw at any time without penalty
• Withdrawal will not affect my current or future dental care

Signatures

Participant Signature: _________________ Date: _______

Investigator Signature: ________________ Date: _______

Witness Signature: ___________________ Date: _______

Contact Information

For questions or concerns: Study Coordinator: [Name] Phone: [Number] Email: [Email]