New Cardiology Clinical Trial Application

PLEASE NOTE: Start up process does not begin until this form is completed and received. Current start-up time: Approx. 4-5 months until Open to Accrual “OTA”

If you plan to have any Sub-Investigator's take part in this trial, please list them here:

Ex: Abbott Laboratories; Biosense Webster Inc.; Merck & Co., Inc.; etc.

Please select any services you foresee may be needed for this trial:

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Please list start and close date for enrollment in this trial:

How many patients do you anticipate enrolling in this particular Trial:

If the service need was snot listed in the dropdown above, please list it here:

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If the service needed was not listed in the dropdown above, please list it here:

Please list any components of this trial which can be covered by insurance, and would be considered standard of care". EX: Imaging, Clinic Visits, Labs, etc.

Please provide at least 3 dates and times when you will be available for a 30 min. check regarding your trial request:

If you have received any documentation regarding this Trial already, please attach it here: Ex: Budget, contract, protocol, selection letter, etc.

Drag and drop files here or