Date: {{$ActivityAssignDate}}

To,

Sun Pharma Laboratories Limited
SUN House,CTS No.201/B/1,Western
Express Highway, Goregaon(E)
Mumbai 400063

Subject: A retrospective, cross-sectional observational survey study to analyze the role of Vortioxetine in patients with depression having cognitive deficits.

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 the data collection plan and DCFs.

  • All the data shared by me will be retrospective in nature.

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


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

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

Yours sincerely,

[Signature]
{{$doctorName}}

(*please put stamp)