Date: {{$ActivityAssignDate}}

To,



Sun Pharma Laboratories Limited
Sun House,
Mumbai



Subject : A multicentre, retrospective, observational, cross-sectional, survey study to analyse the role of Fluticasone Furoate and Vilanterol Powder for Inhalation in Asthma.


In response to your letter dated …………………., I agree to participate in the study as outlined by you.
I understand that:


  • You will provide me with a copy of the data collection plan and …… DCFs.

  • All the data shared by me will be retrospective in nature.

  • The patient’s identity will not be disclosed in the DCF.

My personal details are given below for accuracy of your records.

Name:* {{$doctorName}}
Qualifications:
Specialty
*PAN Card No.
Postal Address:
PIN Code :
Clinic/Hospital Tel. No.:
Residence telephone No:*
Mobile Number :*

*Mandatory to be filled






Yours sincerely,

[Signature]
{{$doctorName}}