AGA Center for GI Innovation and Technology Service Request Form

Requestors will receive a response within 15 business days of submission. For any questions regarding this form, please email agacgit@gastro.org.

Question Title

* 1. Your company information

Company *

Address *

Address 2

City *

State *

ZIP/Postal Code *

Country *

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* 2. Your contact information

First name

Middle initial

Last name

Degree(s)

Position/title

Email address

Phone number

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* 3. Secondary contact information

First name

Middle initial

Last name

Degree(s)

Position/title

Email address

Phone number

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* 4. What services do you seek from the AGA Center for GI Innovation and Technology? (Check all that apply.)

Referrals to key opinion leaders

Assessment of peer-reviewed literature

Meeting with key opinion leaders

Users forum

Clinical trial design consultation

Protocol development

Data review and recommendations

Observational registry study

Other (please specify)

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* 5. What are your desired outcomes in working with the AGA Center for GI Innovation and Technology?

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* 6. What is the desired timeframe for fulfilling the services you seek from the AGA Center for GI Innovation and Technology?

Within 30 to 60 days

Within the next 3 to 6 months

Within the next 12 months

Other (please specify)