Laboratory Medicine
Clinical Study Service Request Form
Thank you for your request to BMC Laboratory Medicine. In order to process your request please complete the information below. Please contact the Clinical Trial Office at CTO@bmc.org first to register the study in Velos.
IRB Number:
IRB Approval Letter:
Funding # or Cost Center:
Please select one:
Federal
Industry
Contact
Information
Principal Investigator:
Name
Phone number
Email
Study Coordinator:
Name
Phone number
Email
Critical Results MD to call:
Name
Phone number
Email
Email to send results (must be a BMC address, if not please enter fax or location below:
Fax to send results:
Location to send results:
Email to send invoices:
Location to send invoices:
Scope of work:
Please describe the scope of work:
Tests requested:
Please lists separately, we will group into panel if needed:
Please lists separately, we will group into panel if needed:
Please lists separately, we will group into panel if needed:
Signature of principal investigator:
Contact Information
