Patient Consent Form

(for disclosure of records)

DEPUY ASR™ HIP RESURFACING SYSTEM AND
ASR™ XL ACETABULAR SYSTEM

Patient Name:
Patient Address:
Patient Date of Birth:

Information about you and your health is sensitive and confidential and normally will not be disclosed to anyone outside the hospital without your express consent, or at your request.

We recommend that you ask your Orthopaedic surgeon or General Practitioner to explain the details of this Patient Consent Form to you before you sign and date the form below.

1.In the context of the DePuy ASR™ Hip Resurfacing System and ASR™ XL Acetabular System (“ASR Products”), I consent to the following being provided to Johnson & Johnson (Thailand) Ltd and Crawford (Thailand) Ltd (collectively the “Companies”), to assist with the evaluation and review described below:

i.Copies of all my medical records and x-rays relating to my original ASR Product implant surgery by [Surgeon’s name]______on/or about [Date]______, to include but not be limited to:

Discharge Summary, physician progress notes; physician orders, operative/procedure records and reports; emergency room record, (if applicable); radiographs; product code and lot number of components used, and all records relating to the surgery and all follow up visits and records.

ii.Copies of all such medical records and x-rays relating to my subsequent revision surgery by [Surgeon’s name]______that occurred in/or about [Date] ______.

iii.The ASR hip implant which has been removed, and any tissue samples, will be sent for inspection and analysis.

  1. I understand that the above information and my ASR Product component(s) will be reviewed by or on behalf of the Companies in order to analyse my experience of and learn more about the ASR Hip product and ascertain whether certain costs related to medical treatment associated with the recall of the ASR Hip product are eligible for reimbursement.
  1. I consent to the Companies using my personal information collected by this review for analysis. I also consent to this information being collected by or passed to any affiliated entities including DePuy International Limited of Leeds, UK and DePuy Orthopaedics, Inc. of Warsaw, Indiana, USA, and any service providers who are working under contract to DePuy International Limited or its affiliated entities to assist with the evaluation and review described above, and all of whom will agree equally to preserve the confidentiality of the personal information.

I understand that I do not waive my rights to pursue legal action by signing this form or by disclosing this information.

This form should be returned to:

Johnson & Johnson (Thailand) Ltd

c/o Crawford (Thailand) Ltd

183 Rajanakam Building, 10th Floor, South Sathorn Road,

Yannawa, Sathorn, Bangkok 10120 Thailand

Toll Free Number: 001800 656 233

Fax Number: +66 2676 5454

Email:

______

Signature of Patient Date

If you are signing on behalf of a patient, your signature below evidences your confirmation that you have the authority to sign this form on behalf of the patient referred to above.

______

Signature of Patient’s representativeDate

______

Name of Patient’s representative

______

Capacity of Patient’s representative

Please note that you have the right to access the personal data held about you. To obtain a copy of the personal information, please write to Johnson & Johnson (Thailand) Ltdc/o Crawford (Thailand) Ltd, 183 Rajanakam Building, 10th Floor, South Sathorn Road, Yannawa, Sathorn, Bangkok 10120 Thailand. We want to make sure your personal information is accurate and up to date. You may therefore ask us to correct or remove any information you think is inaccurate.

Consent form:ThailandOctober 4, 2010