CONSENT FORM

I wish to take part in the evaluation of the products conducted by Black Opal. 

Before agreeing to participate in the evaluation, I understand it is important that I read, understand and agree to the following about the evaluation:

1. The product. The product I will evaluate may be under development and not available to the general public. Black Opal believes the products to be safe but they may not have completed all normal safety evaluation required for a product available to the general public.
2. Follow Instructions. I agree to follow all instructions accompanying the product.
3. Restrictions on Participation. In order to participate in this program it is necessary that I confirm, represent and agree to certain information and/or restrictions.
   1. Sensitive skin
      I have never have any reaction, allergy, sensitization or other types of irritation from any skin treatment or cosmetic preparation and, to the best of my knowledge, I have no sensitivity to any such products.
   2. Skin and Other Health Conditions
      I have no physical condition of my skin which might be adversely affected by the evaluation of the product (s) including, but not limited to, cuts or abrasions in the area where the product is to be applied, dermatitis, eczema, severe acne or sunburned skin. I am not currently under the care of a physician for any serious or life-threatening medical condition
   3. Pregnant/Nursing
      I am neither pregnant nor nursing
4. Consumer Privacy. The data collected from this study is intended to be used by Black Opal in evaluating its products and its marketing. I understand that Black Opal will use reasonable efforts to not release to the general public the information identifying me that is obtained in connection with this study except as is requirement by law or the safety of myself and the public. Information obtained in the study may be widely circulated, so long as my identity is not disclosed.
5. Black Opal Confidentiality I agree to maintain in confidence any and all information about the product or evaluation that I may learn during the course of study. I represent that neither myself nor any member of my family works for a competitor of Black Opal.  I also agree that any product that is given to me by Black Opal as a result of any study is for my own personal use.  I will not barter, resell or return to any store any such products.
6. Withdrawal from Evaluation Participation in the evaluation is voluntary. I understand that I may refuse to participate or I may withdraw at any time without obligation or prejudice. I also understand that my participation may also be discontinued at any time without my consent by the Black Opal staff.
7. Who to contact I understand that if during the hours of 9:00am to 6:00pm EST Monday through Friday, I experience non-serious medical problems or have any questions concerning the product I should contact Customer Service at xxx-xxx-xxxx. In case of an emergency, including a serious adverse reaction, I understand that I should immediately seek medical assistance.
8. Other information If other information is provided on an attachment to this Consent or otherwise provided to me, I confirm that I have or will read such materials and agree to conform to any instructions/restriction provided therein. If I do not understand any such materials, I will not take part in or continue the study until any issues have been clarified by Black Opal and I do understand the information provided.