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Collaboration form
Collaboration form
Clinic or Hospital
Department
Upload Logo
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[Select file]
please upload the logo of your clinic/hospital
Address
Postal code
City
Please enter at least one letter and select a city from the list
Country
Physician responsible for the center
Title
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Mrs.
Mr.
Dr.
Prof.
Prof. Dr.
Other
First name
Last name
Email
(Please provide a valid email address so that we can send you your login details)
Do you have medical staff who can devote the necessary time to enter the required data?
Yes
No
The medical personnel listed below are listed as investigators.
Title
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Mrs.
Mr.
Dr.
Prof.
Prof. Dr.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Prof. Dr.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
add new doctor
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Other
First name
Last name
Email
(please add a valid email address so that we can send the credentials)
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