Date: {{$ActivityAssignDate}}

To,

Ms Rashmi Parekh,

Sr. GM, Senora Division
Sun Pharma Laboratories Ltd.
SUN HOUSE CTS No. 201,
B/1, Western Express Highway,
Goregaon (E),
Mumbai-400063

Subject: To understand the real-life pattern for available strengths of SUSTEN SR Tablets in prevention of preterm birth.

In response to your letter, I agree to participate in the surveillance as outlined by you.


I understand that:


  • You will provide me with a copy of the study plan and prespecified Data Collection Forms (DCF)

  • SUSTEN SR Tablets would be prescribed by me as in my routine practice.

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

  • I will be responsible for seeking patient consent and for verifying the information in the DCF with that of the patient’s case papers and reports.


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

Name: {{$doctorName}}
Qualifications:
Speciality :
Postal Address:
PIN Code :
Clinic or hospital telephone No. :
Residence telephone No. :

Yours sincerely,

[Signature]
{{$doctorName}}