Physician Intake Form

Hello from DaVita Clinical Research! We are excited about your interest in learning more about us and ways in which we can support you research aims. To get started, we need to know more about you and what you are interested in.

Please answer all questions to the best of your ability. Once submitted, someone from DaVita Clinical Research team will be reaching out to you.

By registering and submitting your information (including providing your phone number and/or e-mail address), you are giving DaVita permission to contact you.

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* 1. Site Information:

Physician Name:

Physician Practice and/or Affiliation:

Preferred contact E-mail Address:

Preferred Contact Phone Number:

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* 2. What are you interested in learning more about? (Select all that apply)

Pharmaceutical/device sponsored studies

Investigator initiated research studies

Prospective data studies

General inquiries about how you can collaborate with DCR

Something else:

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* 3. Do you have DaVita credentials/rounding rights?

Yes

If yes, please list facilities with rounding rights below

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* 4. Does your practice utilize DaVita Epic CKD?

Yes

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* 5. Do you have a dedicated and experienced study coordinator?

Yes

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* 6. Are you currently working with other strategic partners on trials (SMO or broker)?

Yes

If yes, please provide details

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* 7. Do you have experience in the conduct of industry sponsored trials?

Yes

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* 8. Please indicate the number of trials conducted at your site:

0-5

6-10

11-15

>15

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* 9. Have you ever been audited by the FDA or received a 483?

Yes

100% of survey complete.