Clinical Trial Form

First Name

Last Name

Company

Business Address

City

State

Zip

Phone

Confidentiality Agreement Required?

Active Pharmaceutical Ingredient (API)?

Chemical Classification of API:

Dosage Form of Study Drug:

Does the API Require Special Handling Procedures?

Is there an IND for your trial?

Stability Information of Finished Product:

Double-Blind Placebo Control:

Randomization:

Number of Subjects:

Duration of Study:

Level of Service, Documentation and Control Required

Expected Timeline:

Other Information Relevant to the Request:

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