A Patient Profile form is required to be filled out before initially submitting any forms on the portal. The completed profile needs to be filled out only once, as it will be stored for future reference in all future form requests.

IMPORTANT: Required fields are marked with an asterisk.

Patient Travel Requests - Air/Rail / Hotel / Ground

 

Kindly indicate the services you will require by checking the appropriate box(es).  
       

  Please check the appropriate travel date from the date of submission
   
   

   SITE/STUDY INFORMATION 
 
Site Number*
Patient Number*
Full Study Number, Protocol Number or BC#*
Sponsor Name*
 
Has this patient transferred from another study?*
If Yes, Indicate which study:

   SITE COORDINATOR INFORMATION 

 

Site Coordinator Name*
Site Coordinator Phone Number*
Site Coordinator Email Address*
Site Address*


 

   PATIENT INFORMATION 
REMINDER
Please keep in mind that for domestic flights within the United States, the name on your airline ticket must match your government-issued ID that will be presented at the airport. For international travel, the name on your airline ticket must match your passport.
First Name*
Last Name*
Date of Birth* |Month/Day/Year (MM/DD/YY)
Gender* Male    Female
Patient or Guardian Contact Phone Number*
Specify:
Home Phone    Cell Phone
Patient or Guardian email* (Please enter NA if they have no email address)
Does a patient or care giver have a credit or debit card?
 (Hotels require this at check in for incidental holds)  		 Yes     No
 

 

 ACCOMPANYING TRAVELERS INFORMATION 
REMINDER
Please keep in mind that for domestic flights within the United States, the name on your airline ticket must match your government-issued ID that will be presented at the airport. For international travel, the name on your airline ticket must match your passport.
Full Name Date of Birth Gender Relationship to Patient Upload Passport (if applicable)
M  F
M  F

Do you or any additional travelers have any special needs or concerns we should be aware of?



 
   TRAVEL REQUEST

Kindly submit only one trip request per form.

Trip
 		 Departure Date Return Date Total Number 
Travelers		 Visit Type
(Please provide this information as it is important factor for us to have as it relates to travel logistics. e.g.; Screening, Baseline, Cycle, Day or Week number etc.)
1 * * *


 

   APPOINTMENT SCHEDULE 

(Please list each of the dates, times and length of each visit in order to manage the arrangements scheduled around the visits)

Date of Appointment
(mm/dd/yyyy)		 Time of Appointment Length of Appointment Comments
Please make sure you use this section to enter the visit type/reason for each appointment
* * *

 

Select and fill in the travel sections that are relevant to your particular request.
  

 

   AIR/RAIL TRAVEL (if applicable - all fields are necessary)

 

Departing From/Preferred Airport or Rail Station
Arrival Destination
Will you be requesting a wheelchair for the airport?   YES     NO

 

 HOTEL INFORMATION  (if applicable - all fields are necessary)

Note: Hotels require credit or debit card at check-in for incidentals

Hotel Location
ADA Room YES   NO
Type of ADA Room or Explain Special Requirements
Number of Beds ONE  TWO
Special Requests
 
  RENTAL CAR (if applicable)
 
Check here if you will be needing a Rental Car  
Comments:
CAR SEAT: If requesting a car seat please specify type:    Infant      Booster                   Weight of Child:
 
   GROUND TRANSPORTATION (if applicable) 


(Please list all transportation requirements)
Enter full address and zip code for each location

Date
(mm/dd/yyyy)		 Pick Up Time
 		 From Address To Address Type

CAR SEAT: If requesting a car seat please specify type:    Infant      Booster                   Weight of Child:

 

OTHER COMMENTS
 
 
 
Click to print a copy for your records before submitting   

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