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ClinicEval Connect- Sponsor
Sponsor
1.
I represent the following type of Sponsor
Pharmaceutical
Biotechnology
Medical Device
Medical Diagnostic
Other (please specify)
2.
Please provide the following information
Company Name
Company Website Link
Your Name
Your Title
Address 1
Address 2
City/Town
State/Province
Zip/Postal Code
Country
Email Address
Phone Number
3.
Please select the therapeutic or specialty areas of focus for your company's current clinical trial needs (
select all that apply
)
Allergy
Anesthesiology
Cardiology
Cardiovascular Surgery
Colon and Rectal Surgery
Critical Care Medicine
Dental
Dermatology
Emergency Medicine
Endocrinology
Epidemiology
Family Practice
Gastroenterology
Geriatric Medicine
Gynecology
Gynecologic Oncology
Hand Surgery
Hematology
Hepatology
Hospice and Palliative Medicine
Immunology
Infectious Disease
Internal Medicine
Medical Genetics
Microbiology
Neonatology
Nephrology
Neurosurgery
Neurology
Nuclear Medicine
Obstetrics
Occupational Medicine
Oncology
Ophthalmology
Oral Surgery (maxillofacial surgery)
Orphan and Rare Diseases
Orthopedic Surgery
Otolaryngology
Pain Management
Parasitology
Pathology
Pediatrics
Perinatology
Plastic Surgery
Podiatry
Psychiatry
Pulmonology
Radiation Oncology
Radiology
Reproductive Endocrinology
Rheumatology
Sleep Disorders
Spinal Cord Injury
Sports Medicine
Surgery (General)
Thoracic Surgery
Transplant Surgery
Urology
Vascular Surgery
Other therapeutic or specialty areas of focus (please specify)
4.
Please select the countries and/or geographic areas in which your company is considering conducting the proposed clinical trial(s) (
select all that apply
)
To be determined
Argentina
Australia
Austria
Belgium
Brazil
Canada
China
Czech Republic
Denmark
Egypt
Finland
France
Germany
Hong Kong
India
Ireland
Israel
Italy
Japan
Korea (Republic of South Korea)
Mexico
Netherlands
New Zealand
Norway
Peru
Philippines
Poland
Portugal
Puerto Rico
Russia
Saudi Arabia
Serbia
Singapore
South Africa
Spain
Sweden
Switzerland
Taiwan
Turkey
Ukraine
United Kingdom
United States
Venezuela
Other or Comment (please specify)
5.
Please select the phase(s) of clinical development and research which best align with your company's current needs (
select all that apply
)
Preclinical
Phase I/Healthy Volunteer
Phase II
Phase III
Phase IV/Investigator Initiated
Observational, Retrospective and Chart Review Studies
Comment (if appropriate)
6.
Approximately how many research sites are you currently considering targeting to achieve your trial enrollment timelines?
7.
Approximately how many subjects are you currently considering targeting for enrollment in the proposed clinical trial?
8.
Please provide any additional comments that might be useful as Cliniceval Solutions researches information relative to your request.
