Sample Assent Form
Fictitious Toothpaste Study
We are asking if you are willing to use our new toothpaste, because we are
trying to learn more about how to prevent cavities in kids your age.
Because you have had 3 or more cavities in the last year, we are asking if
you want to be in a study. It seems like some kids have teeth that never
get cavities, and other kids get lots of them. We hope that our new
toothpaste will help kids who seem to get a lot of cavities from getting
so many cavities in the future. But we won't know if the toothpaste works
until we try it.
If you agree to be in this study, we will ask you to brush your teeth with
You may not like the new toothpaste. The new toothpaste might not work as
You will still have the same dentist if you say no to being in this study.
You can ask any questions that you have about this study. If you have a
Signing here means that you have read this paper or had it read to you and
Signature of Participant ____________________ Date _____________
Signature of Investigator ____________________ Date ____________