You determine if your left-over material can be used in medical research, education of medical students or optimizing medical examinations. You are completely free to choose. In case you object, there will be no consequences at all in the relation with your treating physician or any other person involved in your care. You will receive the same treatment.
In case you do nothing Erasmus MC assumes you do not object against the use of your left-over material for medical scientific research. So, no objection means no action. In case you do object, please fill out the form that is attached to this flyer. If you object your left-over material will not be issued for medical scientific research or educational purposes.
Patiënts who cannot decide on their own
It may be you read this folder as custodian or representative of a patient. For example you are the parent of a child younger than 16 years of age or mentor of a mentally incapacitated patient. In that case you are the one that can object against using the left over materials for medical research.
Medical Research Results
Important scientific findings will be published on the Erasmus MC website. (www.erasmusmc.nl) amongst all other studies. You will not be personally informed about the medical scientific research results performed on your left-over materials. The results may contribute to products for a better treatment and which become commercially available. You cannot claim a share of any profits. On the other hand future patients can benefit from the newly developed treatment options.
For questions, please contact your treating physician. In case you are not satisfied with our services please let us know. You can file your complaint to our complaint officer. You can do this by filling out a complaint form which you can obtain from Erasmus MC receptions, where you can also ask for the complaints officer. You can also obtain the digital form online, which you can return to email@example.com
, or download the form and send it to the secrateriat of complaints with the following address free of charge: Postal address secretariat Klachtenopvang
(No stamp needed)
t.a.v. secretariaat Klachtenopvang
3000 WB Rotterdam
FORM: Object against use of left-over material
In case you DO NOT
object against the use of your left-over material (tissue, blood, body fluids, medical images without recognizable parts and coded data) for medical scientific research and educational purposes you DO NOT
have to fill out this form
Last name and initials: _______________________________________
Date of birth: ______ /______ /______
Gender:O maleO female
Patient number: _____________________________ (The patient number is the 7-digit number in the right hand corner on top of all your personally send communication from Erasmus MC. Without this number we can unfortunately not register your objection. It is the proof you are really the person behind the objection and not taking the right to participate in medical research away from someone else. )
O Objects against the use of left-over materials for medical researh, education of medical students and optimizing medical examinations.
In case you declare the objection for a patient who is not capable in doing so, please print your name and initials as well as you relation to the patient (e.g. parent, partner, representative).
Name and relation: _______________________________________________________________
Place: __________________________ Date: ____ / ____ / ____
Signature of patient or representative (if applicable):
Please return this form at the receptions called Inschrijvingen or mail this filled out form to:
Afdeling Pathologie / Weefselbank
3070 WB Rotterdam
(No stamp needed)