Collection Form

"*" indicates required fields

Equipment info

Kind*

Number of units*

Serial No(s)*

Kind

Number of units

Serial No(s)

Kind

Number of units

Serial No(s)

Study info

Study nr.

Study code / protocol (Sponsor)

Site nr.*

Location details(e.g. at the reception desk)

IMPORTANT: Please be very specific with the location where the unit has to be picked up. e.g. Floor, Department, Room, Route, etc.

Hospital / Institute*

Department

Address*

Postal code*

City*

State

Country*

Tel. of the contact at the site (include country code)*

Fax (include country code)

Contact person at the site*

E-mail address*

CRA / monitor details

Name*

Tel (include country code)

E-mail address

Customer information

Company name*

Ordered by (name)*

E-mail address*

Billingcode

Suggested pickup Date

Additional remarks

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