• 19057

Samples Consent Form

      Part 1. Information Sheet

      Client name*
      Organization name *
      Project title
      Telephone Number*
      Email Address*

      Confidentiality

      All identifying information about the samples' participants will be confidential and masked for subsequent usage. Confidentiality will be maintained including any limitations. The sample provider will be informed and acknowledged in any documents provided from these samples.

      Right to Refuse

      The samples provider may refuse to allow samples to be kept or put restrictions on those samples with no loss of benefits.

      Part II. Certificate of Consent

      If any of the SAMPLE, I have provided for this research project is unused or leftover when the project is completed (Tick one choice from each of the following boxes)
      I wish the remaining samples to be returned.I wish my SAMPLE to be destroyed .I give permission for my sample to be stored and used indefinitely ,informed and acknowledged

      I have read the information, or it has been read to me. I have had the opportunity to ask questions about it and my questions have been answered to my satisfaction. I consent voluntarily to have my samples stored in the manner and for the purpose indicated above. I confirm that I has given the consent freely.

      Name of Participant*
      Signature of Participant*
      Date*

      Sample identification list

      Sample IDIdentificationDescriptionVolume



      Select Appropriate Analysis Mode:


      Additional Comments:

      Additional Sample Information



      Declaration of uncertainty

      Dear Customer


      Although the Proteomics and metabolomics unit takes all precautions to produce an internationally standardized results and associated reports, in some cases, and due to the nature of the samples, we cannot guarantee the reproducibility and outcome of the results.
      This is simply due to the nature of the sample rather than any artifacts due to sample processing, mass spectrometric optimization.


      You are signing on this document to be noticed that our unit won’t bear responsibility of failure of analysis due to the nature of samples.


      Associated prove of optimized procedures is provided within this analysis will be delivered to you in case of analysis failure. In such case, please note that CCHE 57357 will not bear responsibility of reanalyzing the sample again and the unit have the right to reject further analysis of such sample(s) to keep our mass spectrometry clean and optimized