Informed Consent Form
Last updated: January 17, 2021
Capsule Communications Inc. ("us", "we", or "our") operates the www.capsulec.com website (the "Service").
The purpose of this consent form is to give you information about the recruitment process for clinical studies and if you confirm your participation, it means you will have agreed to register in a patient recruitment database for clinical studies. lnitially, your information will be collected and stored in a database. Then, the database will be screened to identify eligible patients for clinical studies.
This form describes the purpose, procedures, benefits and risks of participating in a patient recruitment database for clinical studies and /or market research. lt may contain words that you may not understand. ln that case, please revert to our personnel to explain any words or procedures that you do not clearly understand. You may refuse to take part or withdraw from this patient recruitment database at any time..
Potential Benefits and Risks:
• Opportunity to participate in clinical studies
• Your participation as a subject in a clinical study may provide the medical community with information about the best treatment for your disease condition.
• You may not benefit personally from participating in a clinical study, but by serving as a volunteer, you may contribute new information that may benefit others who suffer from
the similar condition.
• There is a possibility of seeing your medical information by personnel conducting a clinical study.
There will not be any compensation paid to be a part of this patient recruitment database. However, you may be compensated for travel, food and other expenses, which are directly related to your participation in a clinical study.
Your identity and the medical information will remain confidential in our database. The information will be released only to the clinical study doctor / investigators, clinical research organizations, sponsors, as well as regulatory authorities and ethics board members.
Voluntary Participation and Withdrawal
It is entirely your choice whether or not you participate in this patient recruitment database for clinical studies. If you decide not to participate, you may withdraw from registering at any time. Your participation in this database may also be terminated by you or the sponsor after registration in the database.
You are not waiving any of your legal rights by participating in this patient recruitment database, including, for example, the right to seek damages under civil law for clinical research related injury.
Consent by Subject
I have read and understand the information in this informed consent document. I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction. I voluntarily agree to participate in this study until I decide otherwise. I do not give up any of my legal rights by verbally consenting to participate in this study.
Witness for Subjects Who Cannot Read
The study subject has indicated that he/she is unable to read. The consent document has been read to the subject, discussed with the subject and legally authorized representative (LAR), by a member of the study staff, and the subject and LAR have been given an opportunity to ask questions of the study staff before submitting the form.
For Children Who Become Adults
I have been told that my parents/legal guardian agreed for me to participate in this research study as a minor. I have heard and understand the information in this informed consent document. I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction. I voluntarily agree to continue to participate in this study until I decide otherwise. I do not give up any of my legal rights by verbally agreeing to this consent document.
If you have any questions about this Informed Consent Form, please contact our project manager, Ms Priti Chawla at: # 1-416-565-9722 or firstname.lastname@example.org