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IRB #: 20174446Approved:
10/8/2017
Do Not Use After:
9/26/2018STUDY TITLE: Retuning the Nervous System in Youth with Chronic Pain
Healthy Participants Consent Form
FUNDING ORGANIZATION: Cincinnati
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01
Start by reading the instructions on the blank EPAS consent form.
02
Write your name and contact information in the designated fields on the form.
03
Provide a brief description of the purpose or reason for the consent.
04
Specify the exact information or records that you are consenting to release.
05
Indicate the duration of your consent by mentioning the start and end dates.
06
Sign and date the consent form at the bottom.
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If applicable, have a witness sign and provide their contact information as well.
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Make a copy of the completed consent form for your records.
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Submit the original consent form to the appropriate recipient or organization.
Who needs blank epas consent form?
01
Individuals who want to authorize the release of their personal information or medical records may need a blank EPAS consent form. This may include patients who want to share their medical history with other healthcare providers, individuals participating in research studies or clinical trials, or individuals who want to grant access to their health information for legal or administrative purposes.
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