Date: {{$ActivityAssignDate}}

To

Dr. Amey Mane

Sun Pharma Laboratories Ltd
Sun House, Goregaon east,
Mumbai.

Dear Dr Mane,

Subject: Evaluation of Drug utilization pattern of Ticagrelor in patients with Acute Coronary Syndrome: A Retrospective, Cross sectional Study.

In response to your letter dated _________, I give my consent to participate in the above captioned study bearing protocol number SP/CVD/AXCEL-II/RWE-13-2023.


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 :
Specialty :*
Postal Address:
PIN Code :
Clinic or hospital telephone No. :
Residence telephone No. :*
Mobile Number :*

Yours sincerely,

[Signature & Stamp]
{{$doctorName}}