You are being asked to participate in a research study.

Before you agree, the investigator must tell you about (i) the purposes, procedures and duration of the research; (ii) any procedures which are experimental; (iii) any reasonably foreseeable risks, discomforts and benefits of the research; (iv) any potentially beneficial alternative procedures or treatments; and (v) how confidentiality will be maintained.

Where applicable, the investigator must also tell you about (i) any available compensation or medical treatment if injury occurs; (ii) the possibility of unforeseeable risks; (iii) circumstances when the investigator may halt your participation; (iv) any added costs to you; (v) what happens if you decide to stop participating; (vi) when you will be told about new findings which may affect your willingness to participate; and (vii) how many people will be in the study.

If you agree to participate, you must be given a signed copy of this document and a written summary of the research. A copy of the English version Informed Consent form for the study. You may contact ______________________at ____________________ any time you have questions about (name of investigator) (telephone number) the research or about what to do if you are injured.

The Institutional Review Board (research review board) at Piedmont Hospital has reviewed this study in the context of certain federal regulations relating to experimentation involving human subjects. Approval by Piedmont Hospital Institutional Review Board is not an endorsement of this study or its outcome. You may contact the Chairman of the Piedmont Hospital Institutional Review Board at (404)-605-3638 if you have questions about your rights as a research subject.

Your participation in this research study is voluntary and you will not be penalized or lose benefits if you refuse to participate or decide to stop. You are not waiving any of your legal rights by signing this consent form.

Signing this document means that the research study, including the above information, has been described to you orally, and that you voluntarily agree to participate.