PARTICIPANT IDENTIFICATION NUMBER: _________
"Active surveillance with the possibility of deferred treatment"
Please send this completed form to:
I hereby confirm that I have read the patient information form, version 3.3e, d.d. April 26, 2006. I understand the information as stated. I have had the opportunity to ask questions, and any questions have been answered to my satisfaction. I have been provided with enough time to think about participation in this study.
I am aware that participation is voluntary and that I can end my participation to it at any time, without the need to provide a reason. I give consent for access to my medical chart and the research data to competent personnel of the medical inspection and of members of the ethical board.
I give consent to process the obtained information for purposes described in the information for patients form.
The study physician has explained that, if necessary, a repeat biopsy 8 weeks after diagnosis can provide the physician with extra information about my prostate cancer.
I do / do not want to have a repeat biopsy after diagnosis if necessary.
I do / do not give consent to retain my data for 15 years after the end of the research project.
I give consent for participation in the above mentioned research project:
Patients name :_________________ Name physician:___________________
Date of birth:________________ Hospital:_________________________
Street address:________________________ Signature study physician:
Postal code:_____________________ _____________________________
Signature patient:_____________________ Date:____________________________