AnEUploidy: to study the influence of gene number in relation to the development of diseases.

I’ve been informed about the research project comprehensively. I’ve read the information carefully and I was in the opportunity to ask questions. My questions were answered to my satisfaction. I was in the situation I could consider my participation deliberately. I will have the right to withdraw from participation at any moment, without the obligation to give a reason.

I agree to participate in the AnEUploidy research project.

Name:………………………………………………………………. Gender: m/f

Date of birth:………………………………………………………..

I give this permission as the parent or guardian of:

Name patient: ……………………………………………………... Gender: m/f

Date of birth…………………………………………………………

Place……………………..

Date………………………

Signature…………………

To be filled out by the doctor who will send the samples of this patient and/or family.

Above person/persons are known by:

Dr ………………………………………..

Department: …………………………….

Address: .…………………………………

………………………………….

I declare that the above named person has been informed about the project verbally and in writing. Furthermore I declare that withdrawal by this person, at any time during the project, will be of no influence on the quality of care he/she will receive.

Date: …………. Place: ………………. Signature………………………………