BMC Pathology Clinical Trials and Research Requests Supplemental Information Form

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Thank you for your recent request to BMC Pathology. In order for BMC Pathology to process your request, a few additional details are needed. 

Please complete the information below. (Note: If you are requesting tissue from multiple specimens, only one (1) form per IRB protocol needs to be completed.) 

Please contact the Clinical Trials Office at first and register your study in VELOS:

Requester Contact Information

Principal Investigator Contact Information

Funding Information

Study description
Provide a brief description of the study, including tissue type & intended use. Include Accession #, patient first and last name, MRN and block code if known, priority, anatomic site, and minimum requirements

Categorize the research study into one of the following four (4) categories: