Genetic Studies in Mental Illness in Pakistan

CONSENT FORM October 2012

Dr Saqib Mahmood, University of Health Sciences, Lahore

Professor Douglas Blackwood, Division of Psychiatry, University of Edinburgh.
Dr Muhammad Ayub, University of Durham UK. And Queens University Kingston
Canada
I voluntarily agree to participate in this study that has been explained to me by
Dr .
I have read the attached information sheet entitled Population and Genetic Studies in
Mental Illness and have been given a copy to keep. I have been given the opportunity
to ask questions about the project and understand why the research is being done.
I agree to give a sample of blood/Saliva that will be used for the analysis of DNA. It
has been explained to me that some of the blood sample will be stored on a long term
basis at the University of Health Sciences Lahore, University of Edinburgh,
University of Durham, Wellcome Trust Clinical Research Facility (Edinburgh)
Queens University Kingston Canada or other collaborating institutions for use in
future projects, aimed at understanding the genetic influences on disease. I
understand that I will not benefit financially should this research lead to the
development of a new treatment or medical test. By signing this form I consent to,
and make no claim of right in, the unrestricted use of such blood/Saliva samples for
DNA analysis.
I understand that some of these projects may be carried out by researchers, other than
the group of Saqib Mahmood and Professor Blackwood and Dr Ayub, working in the
UK and other countries, including researchers working for commercial companies.
I give my permission for my medical notes to be looked at and information taken
from them to be analysed in strict confidence by Dr Saqib Mahmood and colleagues.
I understand that I am under no obligation to take part in this study and a decision not
to participate will not alter any treatment I receive
I know how to contact the research team if I need to.

Name of subject (block letters)

Date

Name of person taking consent

Date

Signature

Signature