The Pioneer Pelvic Pain Clinic | Albany

Consent for Use of Deidentified Patient Data for Research Purposes

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This consent form is a legal requirement of our funding for the pelvic pain pilot clinic.

Invitation: We would like to invite you to consent to use of deidentified patient demographic data and quality of life scores.

Purpose of data collection: To assess the impact of our pilot clinic on quality of life after multidisciplinary team management of pelvic pain, endometriosis, and chronic pelvic pain syndromes. Outcome data is a mandatory requirement of the grant funding for this pilot pelvic pain clinic.

What would be expected of you: to participate in the pelvic pain clinic. To undertake patient reported outcome questionaries at routine appointment times.

Confidentiality: All responses will be recorded anonymously so that it will be impossible to identify you or any other person. Your name and address will NOT be recorded nor reported to the federal government.

Persons to contact: If you have any questions about the collection of deidentified patient data please contact