AGA Innovation Service Intake Form

Thank you for your interest in engaging the AGA. You will receive a response within 5 business days of submission. For any questions regarding this form, please reach out to us at innovation@gastro.org.

Question Title

* 1. Company information

Name

URL *

Address *

Address 2

City *

State *

ZIP/Postal Code *

Country *

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* 2. Your contact information

First name

Last name

Degree(s)

Position/title

Email address

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* 3. What service(s) is your company interested in? (Check all that apply.)

Meeting with key opinion leaders

User forum

Clinical trial design consultation

Protocol development

Data review and recommendations

Observational registry study

Innovator consultations

Member survey

Other (please specify)

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* 4. List your desired outcome(s) or objective(s) for the service(s) selected above.

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* 5. What is your preferred timeframe for completing the requested service(s)?

Within 30 to 60 days

Within the next 3 to 6 months

Within the next 12 months

Other (please specify)