Alpha-1 Canadian Registry

ALPHA-1 CONSENT FORM

I have been informed about both the Canadian and the International Registry for Alpha-1 Antitrypsin Deficiency. I have read and have understood the information written above for this Registry. I, hereby, give my consent to have my name entered in the Canadian Registry and the International Registry at some future time if it is warranted.

At no time will my name be used or given out for future studies without first being contacted. I agreee that authorized persons may have access to my personal data, provided that confidentiality on the information obtained is maintained.

On this understanding, I agree to have my name and relevant health information entered into the Registry.

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Participant's Name:
Participant's Signature:	_______________________________________________
Date:
Parent or Legal Guardian: (for minors)
Parent's Signature:	_______________________________________________
Date:
Witness' Name:
Witness' Signature:	_______________________________________________
Date:
Please sign form and mail to: Alpha-1 Data Management Centre The Toronto Western Hospital Suite 4-011 Edith Cavell Wing 399 Bathurst St Toronto, Ontario M5T 2S8 OR fax to 416-603-5020 or 416-603-0348.