Thank you for your interest in working with the George and Fay Yee Centre for Healthcare Innovation (CHI). Please complete the following short form so that we can better understand your needs. We look forward to providing you with a free one-hour consultation. Please note that charges for services beyond the initial consult may apply.
General Information

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* 1. Please check all services that you would like collaboration/consultation on (choose all that apply):

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* 2. Please provide a brief description of the specific services you are looking for.

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* 3. Name (of contact person for this project):

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* 4. Email address (of contact person for this project):

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* 5. Phone number (of contact person for this project):

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* 6. Name of Project Lead/Principal Investigator (if different from above):

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* 7. Email address of Project Lead/Principal Investigator (if different from above):

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* 8. Organization of Project Lead/Principal Investigator:

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* 9. Department/Faculty of Project Lead/Principal Investigator:

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* 10. Address of Project Lead/Principal Investigator:

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* 11. Which of the following do you identify as or with? [Please choose the role of the Project Lead/Principal Investigator that primarily relates to this project or request for service]:

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* 12. Are you requesting support for research that is being undertaken by or in collaboration with a Strategy for Patient-Oriented Research (SPOR) Unit, Network or other SPOR entity?

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