W/O, resident of
voluntarily and of my own free will, consent to participate in the research project titled
“” being conducted by Dr.
, who is the principal investigator, in the Department of
I have received a copy of the patient’s information pamphlet related to this project and have read it / it has been read to me. The principal investigator has clarified my doubts to my satisfaction.
I have been informed by the Principal investigator clearly, in a language that I can understand that the main purpose of the project is to study the
Signature of the Participant/ of the Guardian
Signature of Principal Investigator.
Signature of the Witness