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AdhereBookTM Clinical Trial Application Form

1. ORGANIZATION & TRIAL DETAILS

You are invited to complete this form in order to establish your clinical trial or research project in the AdhereBook portal. Several details provided by the Clinical Trial Research Organization or Sponsor are needed for you to complete the form. Please contact them for any missing information.
[Identification of research organization]
Organization Address
[Identification of the project as a research study]
[Name, credentials, institutional affiliation]
Email (Org Admin)(Required)
[Name and email of other researchers who will require AdhereBook access]
[Name]
This question is optional but helps us allocate sufficient resources to the trial.
If you have questions about your rights as a research participant, or wish to obtain information, ask questions or discuss any concerns about this study with someone other than the researcher(s), please describe:

2. YOUR CONSENT

Consent/Assent to Participate in the Research Study(Required)
Your Name(Required)
Person authorized on behalf of the Organization to complete and submit this form.
Date(Required)
Your Email(Required)
Enter your email address. A copy of this form will be sent to you by email.

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