Endodontic Research Study Participation Agreement

Study Information

Study Title: [Insert Study Title] Principal Investigator: [Name], DDS Institution: [Institution Name] IRB Protocol Number: [Number]

Participant Information

Name: ________________________ Date of Birth: _________________ Contact Number: _______________

Agreement Details

1. Purpose of Research

I understand that I am being asked to participate in a research study involving endodontic treatment procedures. The purpose of this study is to [insert specific research objective].

2. Procedures

• Clinical examination of affected tooth/teeth
• Radiographic examination
• Endodontic treatment using [specify technique/material]
• Follow-up visits at [specify intervals]

3. Risks and Benefits

Potential Risks:

• Standard endodontic treatment risks
• [List study-specific risks]

Potential Benefits:

• Contribution to dental research
• [List any direct benefits]

4. Confidentiality

All personal and medical information will be kept confidential according to HIPAA regulations. Data will be stored securely and coded to protect identity.

5. Voluntary Participation

I understand that my participation is voluntary and I may withdraw at any time without affecting my regular dental care.

6. Compensation

[Detail any compensation or reimbursement]

Signatures

Participant Signature: ___________________ Date: _________

Investigator Signature: __________________ Date: _________

Witness Signature: ______________________ Date: _________