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– Sulphuric acid (H SO ) 2 4
• ▷DTC REAGENT
SOLUTION A: 2, 4-dinitro phenyl
hydrazine 0.1mol/L dissolved in
500mL of 4.5M H SO .
2 4
I have been explained about the nature, objective , duration and expected effects of the study and about what I
have to do. I have had the time and the opportunity to enquire about the study and I have been fully satisfied
with the explanation given.
I agree to co-operate with my study doctor and voluntarily give saliva sample for analysis as required in
the study. I agree to follow or observe the specific instruction given by the attending doctor.
I know that I am at libe1ty to withdraw from the study at any time without justifying my decision to withdraw. I
also know that my decision to withdraw will have no effect on my future medical care from this hospital.
I know that the results obtained from this study will be fo1warded to suitable authority . By signing this consent
fo1m, I have not given up any of my legal rights which I am otherwise entitled to as a pa1ticipant in the study.
I am ready to participate voluntarily in this study.
I know that I will get a copy of this consent form which is signed and dated .
Name of the patient Signature of the patient
Date:
I confirm that I have explained the nature , purpose and expected effects of the study to the
patient whose name is provided above.
Study Title:
Comparison of salivary vitamin c, an
antioxidant in smoking and non-smoking adults
1)Particulars of individual:
• Name:
• Age:
• Gender:
• Date and time:
• Address:
2) Past history
• Diabetes mellitus
• Hypertension
3)Personal History
• Diet :(veg/non-veg)
Intake of (fruits/vegetables)
• Smoking (yes/no; if yes duration)
no. of cigarettes :
no. of years :
whether discontinued inbetween :
which of the following
substances have you used
: (cigarette/beedies/beetle
nut/slaked lime)
• Alcohol (yes/no; if yes duration)
4) Drug History
5) Systemic Examination
6) Local Examination
7) Levels Vitamin C
.
SIGNATURE OF SUBJECT
Test Chemicals Qty Amount
in Rs