Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, Hampshire, RG24 9NN
Telephone 01256 314 746 Fax 01256 314 861 Email steve.arnold@hhft.nhs.uk
www.pelicancancer.org
Centre Name / Number:
Study Number:
Patient Identification Number for this study:
Name:
Address:
CONSENT FORM
Title of the project: Prospective analysis of postoperative morbidity, quality of
life and functional outcome after Transanal Total Mesorectal Excision.
Name of Researcher: Mr S J Arnold
1.
2.
Please initial all boxes
I confirm that I have read and understand the information sheet dated July 2015
(version 2.0) for the above study. I have had the opportunity to consider the
information, ask questions and have had these answered satisfactorily.
I understand that my participation is voluntary and that I am free to withdraw at any
time without giving any reason, without my medical care or legal rights being affected.
3.
I understand that relevant sections of my medical notes and data collected during
the study may be looked at by individuals from my treating team and research team,
from regulatory authorities or from the NHS Trust, where it is relevant to my taking part
in this research. I give permission for these individuals to have access to my records.
4.
I agree to take part in the above study.
Name of Participant
Date
Signature
Version 2.0 July 2015
Registered Charity Number 1141911 (England and Wales) Company Limited by guarantee 7264864 (England)