Research AVERT Shock Trial Form - Traumatology, Surgical Critical Care and Emergency Surgery

Research
Traumatology, Surgical Critical Care and Emergency Surgery

AVERT Opt Out Bracelet and Registration Form


First Name	M.I.	Last Name

Mailing Address

City	State	Zip Code

Email Address

Date of Birth
Month	Date	Year

You will receive your Opt Out bracelet, which will read "No AVERT Shock", in 5-10 business days. You must wear your bracelet at all times so that if you are seriously impaired we will know you do not want to participate in this study. This study is expected to last up to 3 years. Thank You!

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