No matter what you decide to do it will not affect your care 1 My tissue may be

No matter what you decide to do it will not affect

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No matter what you decide to do, it will not affect your care. 1. My tissue may be kept for use in research to learn about, prevent, or treat cancer. Yes No 2. My tissue may be kept for use in research to learn about, prevent or treat other health problems (for example: diabetes, Alzheimer's disease, or heart disease). Yes No 3. Someone may contact me in the future to ask me to take part in more research. Yes No
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WHERE CAN I GET MORE INFORMATION? You may call the NCI’s Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) or TTY: 1–800–332–8615 Visit the NCI’s Web sites for comprehensive clinical trials information at or For NCI’s general information about cancer visit SIGNATURE I have read all the above, asked questions, and received answers concerning areas I did not understand. I have had the opportunity to take this consent form home for review or discussion. I willingly give my consent to participate in this program. Upon signing this form I will receive a copy. I may also request a copy of the protocol (full study plan). _____________________ ____________________ ___________ Patient’s Name Signature Date _____________________ __________________ _________ Name of Person Obtaining Consent Signature Date
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  • Summer '07
  • HARRIS-WARRICK,R.M.
  • Chemotherapy, Bone marrow

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