PATIENT’S CONSENT FORM I have had the study explained to me and have read the contents of this form and I have understood the same. I have given the opportunity to ask questions and have them answered to my satisfaction. I am willing to be enrolled in the study of preparation of dissertation on “ROLE OF PHYSICAL APPEARANCE IN HOMOEOPATHIC PRESCRIBING” by Dr. Md. Taha Khan for M.D. (Hom.) course (session 2014 - 2017) Name of the patient ……………………………………………………… Full signature of the patient …………………………………………….. Date ………………………. Signature of the investigator: ………………………………………….. Date …………………........ ……………………………………………….. (FULL NAME OF THE INVESTIGATOR) Signature of the attendant/Guardian (in-case, if the patient is minor)…………………………… Date: ………………………….. ……………………………………………………………. (FULL NAME OF THE ATTENDANT/ GUARDIAN)