Research Participation Agreement for Urgent Care Patients

Purpose

This document confirms your voluntary participation in clinical research activities conducted at [URGENT CARE CENTER NAME].

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: ___________________

Research Study Details

Study Title: ___________________________________________ Principal Investigator: __________________________________ Study ID: ____________________________________________

Consent Declaration

I, the undersigned, hereby acknowledge and agree to the following:

1. Voluntary Participation

   • My participation in this research study is entirely voluntary
   • I may withdraw at any time without affecting my medical care
   • I have received a complete explanation of the study

2. Data Usage

   • I consent to the collection and use of my medical information
   • My personal data will be protected according to HIPAA regulations
   • De-identified data may be used in future research

3. Risks and Benefits

   • I understand the potential risks as explained in the study information sheet
   • I acknowledge that I may not receive direct benefits from participation
   • I have had the opportunity to ask questions about the study

Signatures

Patient Signature: ______________________ Date: __________

Witness Name: _________________________ Witness Signature: _____________________ Date: __________

Investigator Name: _____________________ Investigator Signature: _________________ Date: __________

Contact Information

Study Coordinator: ____________________ Phone: _____________________________ Email: _____________________________

This form must be completed in duplicate. One copy remains with the patient, and one copy is retained in the research records.