MRIDryRunConsentTemplate-UniversityofVirginia.docVIP

Consent of an adult to be in the “Dry Run” MRI portion of a research study In this form you means a person 18 years of age or older who is being asked to volunteer to participate in this study. 1. Participant’s Name______________________________ 2. Medical Record # _______________________________ What is the purpose of this form? This form will help you decide if you want to be part of the “dry run” MRI portion of a research study. You need to be informed about this research procedure, before you can decide if you want to participate. You should have all your questions answered before you give your permission or consent to be in the “dry run” portion of the study. Please read this form carefully. If you want to be in this portion of the study, you will need to sign this form. You will get a copy of this signed form. Why is this research being done? The purpose of this study is to Insert a brief summary of the study As part of this study a Magnetic Resonance Imaging (MRI) scan will be required. The MRI uses a powerful magnet that sends radio waves through the body. This magnet causes the hydrogen molecules within cells to resonate (vibrate). As they move back into place they send out radio waves of their own. The scanner picks up these signals and a computer turns them into a detailed picture. Why is the “dry run” MRI being done? The purpose of the “dry run” MRI procedures is to done ONLY to verify that UVa has the ability to conduct the MRI imaging according to the sponsor’s protocol. It is important that you know the following: You will not receive a copy of this scan and a copy of this scan will not be placed in your medical record. A radiologist (doctor that usually reads MRI scans and makes medical recommendations) will NOT read this scan. Therefore you should not rely on this scan to find any problem. If the MRI staff happens to notice any abnormality then a radiologist will be asked to review the scan and if needed you will be asked t