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