Opt-Out Form

Please ONLY complete this form if you DO NOT want to participate in the Registry

This form is only to be completed if you do not want your information to be collected for the Registry

Declaration by Participant

I do not wish to participate in the Registry and I understand that my decision will not affect my future health care.
I have read the attached Participant Information Sheet.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.

Please complete the following information so your preferences are successfully recorded

Please complete the following information so your preferences are successfully recorded:

First Name

Last Name

Date of Birth required

Phone

Primary Heart Doctor (if known)

Date Registry Information Provided (i.e. card issue or invitation received)

Your opt-out request has been successfully submitted, and will be actioned as soon as possible, within the next 4 weeks. If you have any questions or would like to speak to the research team about your request, please contact us at ChaanzAdmin@chaanz.org.au.