Research Participation Agreement for Concierge Medicine Practice

Purpose

This agreement outlines the terms and conditions for participation in clinical research studies conducted within [Practice Name] concierge medicine practice.

Agreement Terms

1. Voluntary Participation

I, [Patient Name], understand that:

• My participation in any research study is entirely voluntary
• I may withdraw from participation at any time without affecting my concierge medical care
• Declining to participate will not impact my membership status or quality of care

2. Research Activities

By signing this agreement, I acknowledge that I may be:

• Contacted about potential research opportunities
• Asked to participate in clinical trials
• Requested to provide additional medical information
• Invited to complete surveys or questionnaires

3. Data Usage and Privacy

I understand that:

• My personal health information will be protected under HIPAA regulations
• De-identified data may be used for research purposes
• Study-specific consent forms will be provided for each research project

4. Compensation

• Any compensation for research participation will be outlined in study-specific documents
• Research participation is separate from concierge medicine membership fees

Signatures

Patient Name: _________________________ Date: ________________________________

Physician Name: _______________________ Date: ________________________________

Witness Name: ________________________ Date: ________________________________