CONSENT FORM

Short title of project: A study of symptomatic urinary infection in persons with spinal cord
injury

Full title: The effect of different methods of drainage of the neuropathic bladder
on the incidence of symptomatic urinary infection, and adverse events
related to the urinary drainage system in spinal cord injury patients - a
prospective study

The patient should be involved in the completion of the whole of this sheet.

Have you read and understood the Patient Information Sheet? YES/NO

Have you had an opportunity to ask questions, and discuss this study? YES/NO

Have you received satisfactory answers to all of your questions? YES/NO

Have you received enough information about the study? YES/NO

Who have you spoken to?

Dr/Mr/Mrs ______________________

Do you understand that you are free to withdraw from the study? YES/NO

 at any time
 without having to give a reason for withdrawing
 and without affecting your future medical care

Will you permit us to inform your GP that you are participating in this study? YES/NO

I ___________________________________ agree to take part in this study.

(Name of the patient to be inserted)

Where by reason of motor impairment, etc., the patient though competent, is physically unable to
sign, a third party may sign the form to witness the consent. After signing, the witness should state
in brackets that he/she is a witness.

Signature Date

(Patient / Witness to Consent by Patient)

Two such forms should be completed, one to be retained by the subject and the other must be
filed in the clinical case records.