Your browser does not support JavaScript
Please enable JavaScript to make sure proper function of the application
Close
Modal Title
Close
Modal Title
English
X
Collaboration form
Clinic or Hospital
Department
Upload Logo
Your browser does not have Flash, Silverlight or HTML5 support.
[Select file]
please upload the logo of your clinic/hospital
Address
Address
Postal code
Postal code
City
City
Country
Country
Principal investigator (PI) responsible for the center
Title
--Select an option--
Mrs.
Mr.
Dr.
Prof.
Other
Other
Last name
First 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 (1hour per CRF)?
Yes
No
Title
--Select an option--
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
--Select an option--
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
--Select an option--
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 3-5 cases per year?
Yes
No
Comments
Confirm