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, Un exemplaire de la notice d'information m'a été remis. J'ai compris que cette recherche biomédicale était en conformité avec le Code de la Santé Publique, Effect of Falls on Frequency of Atrial Fibrillation and Mortality Risk (from the REasons for Geographic And Racial Differences in Stroke Study), vol.116, pp.1213-1221, 2015.

, J'ai pu poser toutes les questions que je voulais et j'ai reçu des réponses adaptées. J'ai bénéficié d'un temps de réflexion suffisant entre ces informations et le présent consentement, Des informations orales et écrites m'ont été données

, et compris la fiche d'information qui m'a été remise

, J'atteste que je suis affilié à un régime de sécurité sociale

, bien pris note que le promoteur étant un organisme publique et d'Etat, l'assurance étant mise en oeuvre par l'Etat. Elle est donc réalisée par la Direction

, noté que les données recueillies lors de cette recherche demeureraient strictement confidentielles et ne pourraient être consultées que par des personnes désignées par les investigateurs et éventuellement par un représentant des autorités de Santé

, J'accepte le traitement informatisé des données nominatives qui me concernent en conformité avec les dispositions de la loi 78-17 du 6 janvier 1978 relative à l'informatique, aux fichiers et aux libertés et des lois subséquentes qui l'ont modifiée. En particulier, j'ai noté que je pourrai exercer mon droit d'accès et de rectification garanti par les articles 39 et 40 de cette loi en m'adressant auprès de l

, Mon consentement ne décharge pas les organisateurs et le promoteur de cette étude de leurs responsabilités à mon égard, et je conserve tous mes droits garantis par la loi, ANNEXE, vol.6

F. De-consentement, Pour une participation à une recherche biomédicale

, Altération des fonctions cognitives et survenue d'évènements indésirables sous anticoagulants oraux : suivi prospectif de 120 patients âgés de plus de 60 ans à l'HIA Laveran

F. , ARMEES Investigateur principal : Docteur Pierre Laurent MASSOURE, Hôpital d'Instruction des Armées LAVERAN, BP 60149, 13384 MARSEILLE CEDEX 13. Investigateur associé : Interne des Hôpitaux des Armées Christelle NGUYEN-DAC, Hôpital d'Instruction des Armées LAVERAN, vol.125, p.459

, accepte par la présente, de participer à l'étude citée ci-dessus qui m'a été proposée par le Pr/Dr/Interne ?????????????????????

, compris que je suis libre d'accepter ou de refuser de participer sans conséquence pour moi, je pourrai retirer mon consentement à tout moment sans avoir à me justifier et sans conséquence sur la qualité des soins qui me seront prodigués