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Collaboration form
Name of your praxis
Website
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please upload the logo of your clinic/hospital
Adresse
Postal code
City
Principal Investigator (PI) responsible for the center
Title
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Mrs.
Mr.
Dr.
Prof.
Other
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
Do you have a dedicated person as investigator (medical doctor) who can devote the time necessary to complete the online CRFs and upload the required documents?
Yes
No
Title
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Mrs.
Mr.
Dr.
Prof.
Other
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
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Mrs.
Mr.
Dr.
Prof.
Other
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
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Mrs.
Mr.
Dr.
Prof.
Other
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
Is it likely that you will be able to include 5-10 cases per year?
Yes
No
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