Date: {{$ActivityAssignDate}}

To,


Sun Pharma Laboratories Limited

SUN House,CTS No.201/B/1,Western Express Highway, Goregaon(E)

Mumbai 400063


Subject : A retrospective cross-sectional, observational survey study to analyze role of levetiracetam as monotherapy in partial onset seizures with newly diagnosed epilepsy


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 Number:*
Postal Address:
PIN Code :
Clinic/Hospital Tel. No.:
Residence tel. Number:
Mobile Number :*



Yours sincerely,

[Signature]
{{$doctorName}}



(*please put stamp)