|
Date: {{$ActivityAssignDate}}
|
|
To,
Mr M Sundar Rajan,
Sun Pharmaceutical Industries Ltd.
Sun House CTS No. 201 B/1,
Western Express Highway, Goregaon (E), Mumbai - 400063;
Tel: + 91 22 4324 1234/4324
|
|
Dear Mr M Sundar Rajan
|
|
Subject: In-Practice Usage and Performance (IPUP) Study of CHERICOF-12.
|
|
In response to your letter, IPUP/CHERICOF-12/Physician/Stanlife division/April 2023, Dated 20th April 2023, I agree to participate in the study as outlined by you.
I understand that:
-
You will provide me with a copy of CRF and protocol of the study
-
CHERICOF-12 will be prescribed and purchased as in my routine practice.
-
The patients’ identity will not be disclosed in the CRF.
-
No prospective data will be collected/captured in this study
-
I have to report adverse events (AE), if any,
-
You will pay me by cheque a fee of Rs. 5000 (Rs. five thousand only) per patient, and accordingly, on receiving the completed CRFs, of patients’,
as a compensation for the extra time spent in record keeping. The cheque for fee may be drawn in favour of
"………………………………………………………………………………………………………………………………"
My personal details are given below for accuracy of your records.
|
|
Name: |
{{$doctorName}}
|
|
Qualifications: |
|
|
Speciality : |
|
|
Postal Address: |
|
|
PIN Code : |
|
|
Clinic or hospital telephone No. : |
|
|
Mobile Number : |
|
PAN Card Number: *
Please attach a copy of your PAN card for Administrative records
|
|
|
|
Yours sincerely,
|
{{$doctorName}}
[Name]
|
|
}}){kind=logo}