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Name and Clinic NumberApproval Date: March 12, 2021 Not to be used after: March 11, 2022RESEARCH PARTICIPANT CONSENT AND PRIVACY AUTHORIZATION FORM Study Title: Staging of Superficial Esophageal Adenocarcinoma
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01
Start by collecting the patient's personal information: full name, date of birth, and contact details.
02
Include insurance information if applicable, including policy number and provider's contact information.
03
Fill out the medical history section with relevant past and present health conditions, allergies, and medications.
04
Provide a section for emergency contact details.
05
Ask the patient to review the information for accuracy and completeness.
06
Sign and date the leaflet to confirm that the information is correct.

Who needs patient information leaflet informed?

01
Patients attending medical appointments for treatment or evaluation.
02
Medical facilities that require documentation of patient information.
03
Healthcare providers needing to ensure informed consent and understanding of treatment.
04
Insurance companies that may require patient information for claims processing.
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The patient information leaflet (PIL) is a document that provides essential information about a medication, including its usage, dosage, side effects, and precautions.
Pharmaceutical companies and manufacturers are required to file the patient information leaflet as part of their regulatory submissions for new drugs.
To fill out a patient information leaflet, one should include sections like product information, indications, dosage instructions, side effects, and any special warnings or contraindications.
The purpose of the patient information leaflet is to inform patients about the medication in a clear and comprehensible manner, ensuring they understand how to use it safely and effectively.
The leaflet must report information such as the drug name, active ingredients, indications, dosage guidelines, potential side effects, contraindications, and storage instructions.
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