Consent Form to Participate in a Research Project

Consent Form to Participate in a Research Project
A centralised, cloud-based image data storage and viewing platform for oncology patients: A quality improvement pilot study.

for ACT Health

In relation to this study I have been informed of the following points:
1. The aim of the study is to determine whether the use of a centralised, cloud-based imaging data storage and viewing platform improves clinician efficiency and patient management.
2. The study intervention may not be available following completion of the trial.
3. The results obtained from the study may or may not be of direct benefit to my medical management.
4. The study procedure will involve uploading my medical imaging into a centralised cloud storage platform (Aurabox) which will allow my treating doctors to access my medical imaging in one place.
5. Should I develop a problem which I suspect may have resulted from my involvement in this project, I am aware that I may contact Dr Chaturica Athukorala who is the principal investigator of this study via email at chaturica.athukorala@aurabox.cloud.
6. I can refuse to take part in this project or withdraw from it at any time without affecting my medical care.
7. Participation in this project will not result in any extra medical or hospital costs to me.
8. I understand that while the results of the research will be made accessible my involvement and my identity will not be revealed.
9. In giving my consent, I acknowledge that the relevant Aurabox staff, and the Canberra Hospital staff directly involved in the study, may examine my medical records only as they relate to this project.
10. At the end of the study, I may opt to continue to use Aurabox to store my imaging at no charge, or have my data permanently deleted.
You will be contacted by our staff who will assist you to obtain your imaging and upload it onto Aurabox. Please provide your contact details below.
Email *
example@example.com
Phone Number *
By signing you acknowledge that:
- You fully understand and accept the terms mentioned above
- You authorise the release of any medical or other information necessary
- You consent to Aurabox acting as your delegate to obtain your medical imaging from third-party providers, for the express purpose of uploading to the Aurabox platform
Your name *

First Name Last Name
If you are consenting on behalf of someone else, their name

First Name Last Name
Date *

Month Day Year
Date
Signature *

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