PATIENT PROFILES

This form is for submitting a patient profile for patients ENROLLED in a clinical trial.

Important! Required fields are marked with an asterisk.


Date Site Coordinator obtained Patient consent* The consent date MUST BE BEFORE the Profile submission
Site Number*
Patient Number*
Full Study Number, Protocol Number or BC#*
Sponsor Name*

Is this patient moving from another Study? If Yes, Indicate which study:

PATIENT INFORMATION

First Name*
Middle Name
Last Name*
2nd Last Name (if applicable)
Date of Birth* \| Month/Day/Year (MM/DD/YY)
Gender	Male Female
Cell Phone Number
Home Phone Number
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Email Address (to receive all confirmations)*
How does the 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

ACCOMPANYING TRAVELERS INFORMATION

Reminder: Full legal name must match government issued ID that the patient/caregiver
will be using for air travel and presenting at airport check in.

Reminder: Please use Month/Day/Year (MM/DD/YY) format for the Date of Birth

Full Name	Date of Birth	Gender	Relationship to Patient	Phone Number
		M F
		M F

SITE COORDINATOR INFORMATION

Site Coordinator Name*
Site Coordinator Phone Number*
Site Coordinator Email Address*
Site Address*
Country*

OTHER

Tell us about any special requests or requirements we should consider while planning your travel. (ie: 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 or save as a pdf before submitting

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

Secure Internet Services

rev060523