I confirm that I have the opportunity to ask questions. The nature and purpose of the study and it s potential risks/benefits and expected duration of the study, and other relevant details of the study have been explained to me in detail. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reaso n, without my medical care or illegal right being affected. I understand that the information collected about me from my participation in this research and sections of any of my medical notes may be looked at by responsible individuals from BPKIHS. I give permission for these individuals to have access to my record. I hereby give consent to take part in the above study and allow to perform the procedure and any other medical service that may become necessary during the procedure. I also consent for medic al photographs/video and I have been informed that these photographs/video will be used without revealing the identity. I understand that 41 these along with the information I provide may be used in medical record, for purpose of publication in textbook or me dical journal and dissertation purpose, or for medical education. The consent form has been signed by me when I was not under the influence of any drugs. Patient’s Signature……………………………. Researcher/ doctor’s signature……………….. Guardian’s signature…………………. . Date: Witness Signature: If Illiterate I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions and to unders tand the nature of the study. I confirm that the individual has given the consent freely. Researcher/Doctor’s Signature…………………….. Date: Witness signature……………………… Thumb print of participant Right Left