Consent for Donation of Postmortem Brain Tissue

CurePSP Brain Tissue Donation Program Forms

A Diagnostic Service for Families   |   A Research Resource for Scientists

CurePSP Brain Tissue Donation Program for PSP, CBD, and MSA

RESEARCH CONSENT FORM — HOSPITAL PATHOLOGIST

Consent for Donation of Postmortem Brain Tissue for Special Studies and Research Purposes

Name, address, and phone number of next of kin:

Name, address, and phone number of facility from which body or brain is being sent:

I, am the and legal next-of-kin in that capacity and as signer of the accompanying autopsy permit, I do hereby permit and direct that post-mortem brain tissue from the autopsy of the above-named patient be donated for special studies and research on PSP and related diseases.

AUTOPSY INFORMATION

Patient’s Name:

Your Accession Number:

Body refrigerated?

Temperature of refrigerator used to store tissue before shipment:

Clinical Information (Optional)

Age of Patient at Onset:

Major signs and symptoms, neurological & other, with date when first noticed:

Drug therapy during last year:

Agonal circumstances:

Family history:

Sources for Further Information

Physician:

Phone #:

Address:

NURSING HOME

Contact:

Phone#:

Address:

NEXT OF KIN

Name and relationship to patient:

Phone #:

Address:

MEDICAL RELEASE FORM

Copies are to be sent to the doctor(s) who diagnosed or treated the patient.

I/We,

and next of kin to

give permission to release a copy of the medical reports and/or records of above mentioned subject to Mayo Clinic Jacksonville.

Please include history, medical and neurological evaluation, diagnosis, CT or MRI scans, other x-ray reports, electroencephalogram report, medication history, electrocardiogram report and any other pertinent data.

All information will be held in the strictest confidence and should be sent to:

Dr. Dennis W. Dickson
Neuropathology Laboratory
Mayo Clinic Jacksonville
4500 San Pablo Road
Jacksonville, FL 32224

QUESTIONNAIRE

(To be filled out by the family and sent to the CurePSP Brain Bank)

Name of PSP, CBD or MSA patient:

Date of Birth:

Name of the person(s) providing the information below:

Relation to Patient:

Address:

1. Current Diagnosis:

2. Age at onset of symptoms:

3. Is there a family history of PSP, CBD or Parkinson’s disease?

4. What were the symptoms in the early stages:

5. Was the progression of the illness rapid?

How many years?

6. Check any of the following that were present:

7. Personality Changes (Describe):

8. Other Noteworthy Symptoms (Please List):

9. Was the patient right or left handed?

10. Did a neurologist evaluate the patient? A psychologist? A psychiatrist?

11. Was a CT scan or MRI performed?

12. What did the report show?

13. What kind of work did the patient do?

14. Did the patient have any medical illnesses?

15. What medications did the patient take?