Date: {{$ActivityAssignDate}}

To,


Mr Ambrish Sahai


Sun Pharmaceutical Industries Ltd.

Sun House CTS No. 201 B/1,
Western Express Highway, Goregaon (E),
Mumbai - 400 063; Tel: + 91 22 4324 1234/4324


Dear Mr Ambrish Sahai,


Subject: IPUP Study of Cepodem XP


In response to your letter, IPUP/Cepodem XP//ENT/Pharma care/April 2023, dated 1st April 2023, I agree to participate in the study as outlined by you. I understand that:


  • You will provide me with a copy of CRF and full prescribing information on Cepodem XP and Cepodem .& protocol of study

  • Cepodem XP and Cepodem will be prescribed and purchased as in my routine practice.

  • The patients’ identity will not be disclosed in the CRF.

  • No prospective data will be collected /captured in this study.

  • I have to report serious adverse events (SAE), if any, immediately to your monitor or to you in the AE reporting form.

  • You will provide the assistance of a monitor to collect the CRF’s

  • You will pay me by cheque a fee of Rs. 5000 (Rs Five thousand only) per patient, and accordingly, on receiving the completed CRFs, of these - patient’s, as a compensation for the extra time spent in record keeping. The cheque for fee may be drawn in favor of

    • “…………………………………………………………………………………………………………………………………………………………..”

My personal details are given below for accuracy of your records.
Name: {{$doctorName}}
Qualifications:
Speciality:
Postal Address:
PIN Code :
Clinic/Hospital Tel. No. :
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* PAN Card No. :

* Please attach a copy of your PAN card for Administrative records


Yours sincerely,

[Signature & Stamp]
{{$doctorName}}