Forms  |  Links  |  Site Map  |  Email This Page
 
 

ER maintains a comprehensive database of experienced clinical investigators.

If you are interested in becoming part of the ER database, please complete the form below. You can also use this form to request additional information about ER or to forward questions or comments to ER.

* Denotes required fields.

Check all that apply:
MD Phd DO
Other please indicate:
   
* First Name:
Middle Initial:
* Last Name:
* Address:
Suite/Floor:
* City:
* State:
* Zip:
* Daytime Phone:
* Evening Phone:
Fax Number:
* E-mail:
Medical Specialty:
Board Certified
Yes No
Location:
Private Practice SMO Hospital
University Other please indicate:
   
Institution
  
Name of Institution:
Institution Address:
Suite/Floor:
City:
State:
Zip:
IRB Type:
Central Local
IRB Name:
Frequency of IRB Meetings
   
 
Contact Person
  
* First Name:
Middle Initial:
* Last Name:
* Phone:
Fax Number:
* E-mail:
   
 
Previous Clinical Trial Experience (check all that apply):
Phase I Phase III
Phase II Phase IV
   
Allergy/Immunology Nephrology
Anesthesiology Neurology
Arthritis Oncology
Asthma Ophthalmology
Cardiology Orthopedics
Cystic Fibrosis Otolaryngology
Dental Pain Management
Depression Psychiatry
Dermatology Pulmonary Diseases
Diabetes Rheumatology
Endocrinology Sinusitis
Emergency Medicine Sexual Dysfunction
Gastroenterology Surgery
Gene Based Therapies Urology
Heart Failure Vaccine
HIV Weight Loss
Infectious Diseases Women's Health
Pediatrics (specify):
Other (specify):
 
Comments/Questions:
 
 

 
 
© Copyright 2004 Effective Research, Inc. All Rights Reserved
Developed by Delgar.net