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Application Form for Kidney-PATCH
1.
First Name:
2.
Last Name:
3.
Designation: (ex. MD, PhD, etc.)
4.
Company Name:
5.
Title:
6.
Phone Number:
7.
Email Address:
8.
Company Type:
Biologic
Device
Drug
Other (please specify)
9.
Indication:
Application of Approved Primary Adult Indication to Children
Pediatric only
10.
What stage of pediatric study planning? (checkbox)
Pre-protocol development
Post-protocol development
Patient Population:
11.
Disease Area:
12.
Age Ranges:
13.
Estimated Sample Size (if known):
14.
Geographic Areas of Interest:
Current Progress,
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