Date: {{$ActivityAssignDate}}

Dear Dr. {{$doctorName}},

Subject: Real world evidence survey to assess the GERD patient management and usage of Sompraz-D in the treatment of GERD

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 having questions about GERD disease and its management and, Sompraz-D real life experience of its effectiveness and tolerability.

  • No any prospective data will 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:
Speciality :
Postal Address:
PIN Code :
Clinic or hospital telephone No. :
Residence telephone No. :

Yours sincerely,

[Signature]
{{$doctorName}}