Date: {{$ActivityAssignDate}}

Subject: Utilization pattern of SUBA Itraconazole 130MG in real life scenario

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 data collection form.

  • This data collection form will be have questions about fungal infections and Alcros SB 130MG real life experience.

  • Prospective data will not be captured in this study

  • You will provide the assistance of a monitor to verify and to collect the DCF.

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

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

Yours sincerely,

[Signature & Stamp]
{{$doctorName}}