Medipense » AdhereBookTM Trial Application

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.

Organization Name(Required)

[Identification of research organization]

Organization Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trial title(Required)

[Identification of the project as a research study]

Principal Investigator (Org Admin)(Required)

[Name, credentials, institutional affiliation]

Email (Org Admin)(Required)

Enter Email Confirm Email

Phone (Org Admin)(Required)

Co-Investigator(s) (Other Researchers)

[Name and email of other researchers who will require AdhereBook access]

Study Sponsor

[Name]

How many people are expected to take part in this study?

This question is optional but helps us allocate sufficient resources to the trial.

When will the study begin and end?

For more information

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

Your Name(Required)

Person authorized on behalf of the Organization to complete and submit this form.

First Middle Last

Date(Required)

Your Email(Required)

Enter your email address. A copy of this form will be sent to you by email.

Enter Email Confirm Email

1. ORGANIZATION & TRIAL DETAILS

2. YOUR CONSENT

Pin It on Pinterest