Date: {{$ActivityAssignDate}}

To,


Sun Pharmaceutical Industries Ltd,

Sun House, Goregaon East

Mumbai


Subject : In-practice Usage and Performance Survey of Faronem ER


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


  • You will provide me with a copy of the survey questionnaire

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


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

Name:* {{$doctorName}}
Qualification:
Specialty
Postal Address:
PIN Code :
Clinic/Hospital Tel. No.:
Mobile No.:



Yours sincerely,
{{--

--}}

{{$doctorName}}
[Stamp]