Research Participation Agreement and Consent Form

Study Information

Title of Research Study: [INSERT STUDY NAME] Principal Investigator: [INSERT NAME], MD Sponsoring Institution: [INSERT INSTITUTION] IRB Protocol Number: [INSERT NUMBER]

Participant Information

Name: ________________________ Date of Birth: _________________ Medical Record Number: ________

Purpose and Procedures

I understand that I am being asked to participate in a research study involving:

• Orthopedic surgical intervention
• Non-surgical treatment protocol
• Medical device testing
• Other: ___________________

Study Duration and Visits

Estimated participation period: ____ months Number of required visits: ____

Risks and Benefits

Potential Risks

• Surgical complications (if applicable)
• Treatment-related side effects
• [Additional study-specific risks]

Potential Benefits

• Access to novel treatments
• Contributing to medical research
• [Additional study-specific benefits]

Financial Considerations

• Study-related costs covered: [SPECIFY]
• Participant compensation: [SPECIFY]
• Insurance billing details: [SPECIFY]

Participant Rights

1. Voluntary participation
2. Right to withdraw at any time
3. Privacy protection under HIPAA
4. Access to study results

Signatures

Participant Signature: _________________ Date: _______ Investigator Signature: ________________ Date: _______ Witness Signature: ___________________ Date: _______

Contact Information

Study Coordinator: [INSERT NAME] Phone: [INSERT NUMBER] Email: [INSERT EMAIL]