Please print this form and mail it to Dr. Catalona at the address listed at the bottom of this form.

MEDICAL CONSENT & AUTHORIZATION

TO:

Washington University School of Medicine
Division of Urology
Department of Surgery
St. Louis, Missouri 63110

To Whom It May Concern:

I have donated a tissue and/or blood sample for Dr. William J. Catalona's research studies. Please release all of my samples to Dr. Catalona at Northwestern University upon his request. I have entrusted these samples to Dr. Catalona to be used only at his direction or with his express consent for research projects.

Signature

Printed Name

Date

Street Address

City

State

zip code

Telephone: Area Code & Number

E-Mail

SEND THIS SIGNED AND COMPLETED FORM TO:

William J. Catalona, M.D.
Professor of Urology, Northwestern University Feinberg School of Medicine
c/o Northwestern Faculty Foundation
675 N. St. Clair, Suite 20-150
Chicago, IL 60611