Colpitts Clinical Profile Screen Form

  

 

Patient Profile - Screening

IMPORTANT:  Required fields are marked with an asterisk.
 
Site Number*
Patient Number*

Full Study Number, Protocol Number or BC#*
If not known, use "ScreenMMDDYY" (date of visit)
If not known, use "ScreenMMDDYY" (date of visit)
Sponsor Name*
 
Has the patient moved from another Study? 
If Yes, Indicate which study:

 

   PATIENT INFORMATION

Name must match government issued ID that patient will be using for domestic travel 
and match name on passport for international travel. 
 

First Name*
Middle Name
Last Name*
2nd Last Name (if applicable)

Date of Birth*
(If no air travel and/or bank transfers, use 00/00/0000)
Mobile Phone Number
Home Phone Number
Address Line 1*
Address Line 2
City*
Country*
Postal Code*
Email Address (to receive all confirmations)*
How does patient prefer to be contacted? Home Phone  Cell Phone   Email
Does a patient or care giver have a credit or debit card? (Hotels require this at check in for incidental holds)   Yes      No
English Speaking? If not, enter native language

 

PASSPORT INFORMATION (required for travel outside of home country)

 

Passport Number
Expiration Date
Country of Issue
Date of Birth
Gender Male  Female
Attach copy of Passport
 
If Accompanying Traveler, relationship to Patient
Phone Number of Caregiver
 
   ACCOMPANYING TRAVELERS INFORMATION
 
Full Name Date of Birth Gender Relationship to Patient Upload Passport (if applicable)
M  F
M  F
 
 SITE COORDINATOR INFORMATION
  
Site Coordinator Name*
Site Coordinator Phone Number*
Site Coordinator Email Address*
Site Address*
Site Country*
 
   OTHER

 


Tell us about any special requests or requirements we should consider while planning your travel.  (frequent flyer #s, wheel chair; dietary restrictions; etc.)

Note: Please do not submit your travel service request in this section. Instead, use the dedicated travel request link on our portal.
 
 
 
Click to print a copy for your records before submitting   

LuxSci helps ensure HIPAA-Compliance for email and web services.
Secure Internet Services

Copyright © Colpitts Clinical