Dementia Research Consent Form

Document informed consent from a participant, their representative, and a witness to take part in a dementia research study, with a record of each required signature.

Use this template

Page 1

Study Title

Purpose of the Study

Study Procedures

Risks and Benefits

Confidentiality Statement

Contact Information for Questions

Page 2

An Agent Will Sign This Consent on Behalf of the Participant

Yes No

A Witness Will Also Sign This Consent

Yes No

Participant Consent Statement

Name

Nombre

Apellido

Signature

Sign here

Date Signed

Agent Consent Statement

Name of Agent

Nombre

Apellido

Signature of Agent

Sign here

Date Signed

Witness Consent Statement

Name of Witness

Nombre

Apellido

Signature of Witness

Sign here

Date Signed

Researcher Certification Statement

Name of Researcher

Nombre

Apellido

Signature of Researcher

Sign here

Date Signed

2nd Researcher

A Second Researcher Is Also Certifying This Consent

Name of Researcher

Nombre

Apellido

Signature of Researcher

Sign here

Date Signed

Dementia Research Consent Form

Page 1

Page 2

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