Date: {{$ActivityAssignDate}}

To,


Dr. Amey Mane


Sun Pharmaceutical Industries Limited

Sun House, 201 B/1,
Western Express Highway, Goregaon (East), Mumbai,
Mumbai - 400 063


Dear Dr Mane,


Subject: Evaluation of Drug Utilization Pattern of Rosuvastatin in Indian Hypertensive patients with Dyslipidemia with history of PCI or CABG for Coronary Artery Disease (ROSULEAD II Study)


In response to your letter dated _________, I give my consent to participate in the above captioned study bearing protocol number SP/CVD/ROSULEAD-II/RWE-09-2023.

I understand that:


  • You will provide me with a copy of the study Protocol and the requisite number of Data Collection forms (DCFs)

  • The DCFs will capture data as defined in the Protocol, including laboratory results as prescribed and performed in accordance with my routine clinical practice and no fresh laboratory or any investigations will be conducted for the said study

  • The patient’s identity shall not be disclosed in the DCF

  • I will ensure to capture all available information accurately and completely in the DCF provided

  • I understand and agree to allow an independent CRO to visit the study center and compare the information supplied in the DCF to that in medical records


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

Name: {{$doctorName}}
Qualifications:
Registration Number:
Speciality:
Postal Address:
PIN Code :
Clinic/Hospital Telephone Number :
Residence telephone Number :
Mobile No. :

Yours sincerely,

[Signature & Stamp]
{{$doctorName}}