Date: {{$ActivityAssignDate}}

To,


Sun Pharma Laboratories Limited

SUN House,

Mumbai.


Subject : A multicentre, retrospective, observational survey study to analyse the role of fixed dose combination (FDC) drug of paroxetine and clonazepam in elderly patients with co-morbid depression and anxiety


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 :*

*Mandatory to be filled




Yours sincerely,

[Signature]
{{$doctorName}}