GENERAL INVESTIGATOR INFORMATION

Please complete this page by providing investigator information and the investigator's clinical research experience. If you have questions, please email jctg@jefferson.edu

* 1. Investigator FIRST Name

* 2. Investigator LAST Name

* 3. Specialty/Discipline

* 4. Sub-specialty

* 5. Institution Information

* 6. Fax number

* 7. Approximate number of patients you currently see at your facility in a...

  1-5 6-10 11-20 21-30 31-40 41-50 51-100 100+
... day
... week

* 8. Do you have a patient database?

* 9. Number of clinical staff on site (i.e. 3 MD's, 4 RN's)

* 10. Check all that is treated at your practice

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