DHEA Trial: consent and randomization form

DHEA and Unexplained Infertility clinical trial

FORM 2 - Consent and Randomization

This form is to be completed by a staff member. Please fill in ALL fields, as any participant with incomplete data will be ineligible for further analysis.

Study ID:

Study site location:

Patient Number:

(IF CHR, enter CHR-NY)

Patient's first name:

Last name:

Middle initial:

Age:

Date of birth:

Baseline FSH:

Estradiol (mIU/ML):

Cycle length (days):

Duration of infertility (months):

Normal HSG with 1 year?
Yes
No

Normal semen analysis?
Yes
No

Has the participant signed the informed consent?
Yes
No

Doctor Comments:

Attention Staff Member: In addition to submitting the above information, this form must also be accompanied by the following three items:

1. Copy of HSG report
2. Copy of semen analysis
3. Copy of informed consent

These documents should be either:

Faxed to:
Dr. Barad at 212.994.4499

OR Scanned and forwarded via email to:
dbarad@thechr.com

OR mailed in hard copy to:
     CHR
     c/o Dr. David Barad
     21 E. 69th St.
     New York, NY 10021

DHEA Study —

DHEA and Unexplained Infertility clinical trial

FORM 2 - Consent and Randomization