Before you decide to take part in this study, we would like to make sure you have read and understood the Participant Information Sheet. Please ask the research team if you have any questions.
By completing this consent form (in the presence of a member of the research team), you confirm that you understand the nature of the study and agree to take part on the basis described.
You may take this form home and return it at your study appointment. You do not have to decide today.
Consent statements
Please confirm each of the following statements applies to you. Checked items indicate agreement.
Information sheet: I confirm that I have read and understood the Participant Information Sheet (Version 1.0, 2025) for the EyeMap.ai Retinal AI Validation Study. I have had the opportunity to consider the information and ask questions, which have been answered satisfactorily.
Voluntary participation: I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, and without my medical care or legal rights being affected.
Data use: I understand that my anonymised fundus images and questionnaire responses will be used for ophthalmic AI research, including model training and validation.
Confidentiality: I understand that my data will be treated in strict confidence and that no information that could identify me will appear in publications or presentations arising from this study.
Data retention: I understand that anonymised data may be retained for up to 10 years following the end of the study, and that once fully anonymised, it may not be possible to withdraw my specific data contribution.
Not a medical diagnosis: I understand that any AI output from analysis of my retinal image is for research purposes and does not constitute a medical diagnosis. I will discuss any findings with my optometrist or GP.
Agreement to participate: I agree to take part in the EyeMap.ai Retinal AI Validation Study as described in the Participant Information Sheet.
Participant declaration
PARTICIPANT ID (researcher to complete)
Researcher declaration
Once signed, one copy is retained by the participant and one by the research team. Do not leave this form with the participant until it has been counter-signed by the researcher.