मरीज सहमती पत्र

मुझे अध्ययन के बारे में प्रश्न पूछने तथा परिवार और मित्रों के साथ इसके बारे में विचार करने का अवसर मिला है
I मैं समझता / समझती हूँ और स्वीकार करता / करती हूँ, कि यदि मैं अध्ययन में भाग लेना जारी रखता/रखती हूँ
तो शायद मुझे इससे सीधे तौर पर व्यक्तिगत लाभ ना हो | मैं समझता /समझती हूँ कि इस अध्ययन का उद्देश्य
क्या है , मैं इसमें पहले से ही किस तरह शामिल हूँ, मैं पष्टि
ु करता /करती हूँ कि अध्ययन में मैं अपनी खुद
की स्वतन्त्र इच्छा से भाग ले रहा हूँ, और मैं समझता/ समझती हूँ कि मैं किसी भी समय और किसी
भी कारण से, इससे बाहर निकल सकता / सकती हूँ, और इस से मेरी मेडीकल दे खभाल या मेरी कानन
ू ी
अधिकारो मे कोई प्रभाव नही पड़ेगा।
मैं बताए गये अध्ययन में भाग लेने के लिये सहमत हूँ /

मरीज का नाम::…………………… तारीख……………… हस्ताक्षर………………………….....

शोधकर्ता का नाम::………………. तारीख…………… हस्ताक्षर…………………………….

PATIENT CONSENT FORM

THIS IS TO CERTIFY THAT I AM ACKNOWLEDGED OF THE PRESENT STUDY IN WHICH I
AM ENROLLED AS A SUBJECT, I AM WELL AWARE THAT I HAVE TO ABIDE
COMPLETELY AS PER THE INSTRUCTIONS GIVEN TO ME DURING THE COURSE AND
AFTER TREATMENT. I HAVE ALSO BEEN EXPLAINED THE AIM, OBJECTIVE AND
POSSIBLE OUTCOMES OF THE TREATMENT THAT I AM UNDERTAKING AS A PART OF
THIS STUDY.
I ALSO CERTIFY THAT I HAVE READ AND UNDERSTOOD THE ABOVE.
I ACKNOWLEDGE THAT MY QUESTIONS, IF ANY ABOUT INQUIRIES SET FORTH ABOVE
HAVE BEEN ANSWERED TO MY SATISFACTION. I WILL NOT HOLD MY DENTIST OR ANY
OTHER MEMBER OF HIS/ HER / STAFF, RESPONSIBLE FOR ANY ACTION THEY TAKE OR
DO NOT TAKE BECAUSE OF ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE
COMPLETION OF THE FORM.

………………………………………………………… ………….
SIGNATURE OF PATIENT/LEGAL GUARDIAN DATE
………………………………………………………… ……………..
SIGNATURE OF RESEARCHER DATE
 PATIENT PROFORMA

CLINICAL EVALUATION

NAME OF THE PATIENT: O.P.D NO:

AGE: SEX:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST DENTAL HISTORY:

MEDICAL HISTORY:

FAMILY HISTORY:
 GINGIVAL INDEX –SILNESS AND LOE 1963

BLEEDING ON PROBING INDEX-Ainamo and Bay(1975)

POCKET PROBING DEPTH (in mm)

 TEERTHANKER MAHAVEER DENTAL COLLEGE & RESEARCH CENTRE
MORADABAD
DEPARTMENT of PERIODONTOLOGY AND IMPLANTOLOGY.

PATIENT / PARTICIPANT INFORMATION SHEET

FOR STUDY ON - “ASSESSMENT OF GINGIVAL CREVICULAR FLUID LEVELS OF HUMAN BETA

DEFENSIN-1 IN PERIODONTAL HEALTH AND DISEASE”

Name of the investigator/guide – Dr. Rahat Saleem / Dr. Gouri Bhatia

Purpose of this project/study – To compare the GCF levels of beta defensin-1 in individuals with
and without periodontal disease and assess the immunomodulatory activity of beta defensin-1.

Procedure/methods of the study – Patients will be divided into Group 1(Healthy individuals),
group 2 (Individuals with gingivitis) and group 3(Individuals with periodontitis) each comprising of
20 subjects. Samples will be collected from 2 sites in each individual and biochemical analysis will
be performed using ELISA.

Expected duration of the subject participation – One time

The benefits to be expected from the research to the participant or to others and the post-trial
responsibilities of the investigator – This study will help us to determine the role of beta defensin-
1 in periodontal health and disease so as to introduce a target specific treatment protocol for
periodontal diseases in future.

Any risks expected from the study to the participant – No risk.

Maintenance of confidentiality of records – Confidentiality of all the patient records will be

maintained

Compensation for participating in the study - None

Compensation to the participants for foreseeable risks and unforeseeable risks related to
research study leading to disability or death. – Will be dealt in case of such an event.

Freedom to withdraw from the study at any time during the study period – Yes.

Data generated from the study will be used to plan treatment for similar cases in the future.

Address and mobile number of the Principal investigator (PI): Old Girls hostel, Room no. 422,
TMU, Delhi Road, Moradabad – 244001. Ph. 7006050104

उपर्युक्त विस्तार से मुझे हिंदी में समझाया गया है

Signature of the investigator: Signature of the participant:

Place:

Date: