Research Participation Agreement for Plastic Surgery Clinical Trials

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record Number: _________

Study Details

Principal Investigator: _______________ Study Title: ________________________ Protocol Number: ___________________

Agreement Provisions

1. Voluntary Participation

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

2. Study Procedures

• I agree to undergo the following procedures: [List procedures]
• I consent to photography/imaging for research documentation
• I will attend follow-up appointments as scheduled
• I will complete all required questionnaires and assessments

3. Risks and Benefits

• I have been informed of potential risks including: [List risks]
• Potential benefits have been explained to me: [List benefits]
• I understand there may be unforeseen risks

4. Confidentiality

• My personal information will be protected
• Data will be coded and stored securely
• Results may be published without identifying information

5. Compensation

• Research-related costs covered: [List covered costs]
• Additional compensation (if any): ____________

Signatures

Participant Signature: _________________ Date: _______

Investigator Signature: ________________ Date: _______

Witness Signature: ___________________ Date: _______

Contact Information

Principal Investigator: [Contact details] Research Coordinator: [Contact details] IRB Office: [Contact details]