Research Visit Only

To be completed by Internal Research Staff

Visit/Procedure Information


Appointment Date:

/ /  * mm/dd/yyyy

Procedure to be done:

 *

Physician's Name:

 *

Facility:

 *

Study Name:

 *

Principal Investigator:

 *

Professional Fees Associated With Visit?

Technical Fees Associated With Visit?


Patient Information

Patients Legal

Last Name:

 *

First Name:

 *   M.I.

Date of Birth:

/ /  * mm/dd/yyyy

Sex:

 *

Address Line:

 *

Address Line 2:

City:

 *

State:

 *

Zip Code:

 *

Phone:

 *

Submitter


Coordinator:

 *

Phone/Email for contact:

 *

Research Finance
1687 Tullie Circle NE
Atlanta, GA 30329