Date: {{$ActivityAssignDate}}

To,

Amit Shukla

Sun Pharmaceutical Industries Ltd.
Sun House, CTS No. 201 B/1,
Western Express Highway, Goregaon (E),
Mumbai - 400 063; Tel: + 91 22 4324 1234/4324

Dear Mr. Amit Shukla

Subject: In-Practice Usage and Performance (IPUP) Study of Mox-CV

In response to your letter, IPUP/Mox-CV /Maxxim /May’23, dated 5th May, 2023, I agree to participate in the study as outlined by you.


I understand that:


  • You will provide me with a copy of the study plan, CRF and full prescribing information Mox-CV.

  • Mox-CV will be prescribed and purchased as in my routine practice.

  • The patients’ identity will not be disclosed in the CRF.

  • I have to report serious adverse events (SAE), if any, immediately to your monitor or to you in the AE reporting form.

  • You will provide the assistance of a monitor to verify the information in the CRF with that in the patients’ case papers and reports.

  • You will pay me by cheque a fee of Rs. {{$contractAmount}}/- , and accordingly, on receiving the completed CRFs, as a compensation for the extra time spent in record keeping. The cheque for fee may be drawn in favor 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,

[Signature]
{{$doctorName}}