Owner Consent for Vhup Venipuncture Procedure

VENIPUNCTURE OWNER CONSENT FORM

Official Use Only This protocol has been approved by the [Ryan –VHUP/Widener-NBC] Privately –Owned Animal Protocol Committee and the University of Pennsylvania Institutional Animal Care and Use Committee. POAP # .

PRINCIPAL INVESTIGATOR List name(s), telephone number(s) and e-mail address(es) of principal investigator(s).

PURPOSE OF STUDY As the owner or duly authorized agent for the owner of ______(insert name of pet), I grant permission to have my “insert animal species” participate in a Ryan Veterinary Hospital of the University of Pennsylvania clinical study to determine (draft a reasonably complete explanatory statement of the information to be gleaned from the study).

VENIPUNCTURE AUTHORIZATION This study requires that “insert amount in ml,” the equivalent of “__” teaspoon(s), of blood be obtained from my pet to measure “insert what is being measured.” The risk involved in drawing blood for this study is minimal. However, I accept that the hair may be clipped in some cases to facilitate visualization of the vein and understand that my “insert animal species,” may experience mild redness, bruising, or itching at the collection site.

I understand that the results of this test may not directly benefit my pet, but may provide veterinarians with a better understanding of “briefly describe disease, medical condition, etc.” My participation in this study is entirely voluntary and my refusal to participate will not affect my pet’s care in any way.

I have been given the opportunity to ask questions and have them answered to my satisfaction. If I have additional questions regarding this particular research study, I may contact the clinician by telephone or e-mail number above.

By signing below, I acknowledge that I am over the age of 18 and consent to having the described venipuncture procedure(s) performed on my “insert animal species” for the purposes of the study set forth herein.

Ryan-VHUP Case #: Pet’s Name: Date: Client/Owner/Agent’s Printed Name: Client/Owner/Agent’s Signature: Clinician’s or Attending Staff Person’s Signature: