Page:PARAMOUNT Eli Lilly Informed Consent Document.djvu/11



To take part in this study and to allow the use and disclosure of my personal health information for the purposes of the study, I must sign and date this page.

By signing this page, I confirm the following:
 * I give permission for my personal health information and study data to be maintained, used and shared as described in this document


 * I have read the Subject Information and Consent Form, and have had time to think about whether or not I want to take part in this study.


 * All of my questions about the study or this form were answered to my satisfaction. If I did not understand any of the words in this form, the study doctor or a member of the study staff explained them to me.


 * I voluntarily agree to allow photographs to be taken of my wound for the study.


 * I voluntarily agree to take part in the study, to follow the study procedures, and to provide necessary information to the study doctor or other staff members, as requested.


 * I understand that I may freely choose to stop being a part of this study at any time.


 * I have received a copy of the Subject Information and Consent Form.

H3W-EW-S124 (b) Version: 26-October-2009