Clinical Research Center

Baird 7 - MCHV Campus

Outpatient Scheduling Form

You may schedule via this form at any time. If you have questions, please contact Lee Devino, (847-2793), at the CRC, Monday through Friday, 7:00 a.m. to 2:00 p.m.


Outpatient Scheduling Information

When scheduling your outpatient visits please fill out all information under the appropriate column. Press the TAB key to move from field to field.

Any visit involving controlled research meals must be scheduled at least one week in advance.  Other visits need to be scheduled at least one business day in advance.

If a study needs to have samples shipped on the same day in which they are drawn, the bloods must be drawn no later than 2:30 p.m. so that they can be processed and be ready to ship by the 3:00 p.m. Fed-Ex deadline.

No patient may participate in any phase of a study unless there is current signed informed consent on file at the CRC.

When the volunteer signs the consent form the CRC needs the original copy. The patient may bring it with him/her or you can put it in the campus mail to Lee Devino, Baird 7, MCHV Campus.

If the patient has a patient ID or subject number, please put in the Visit #/Test section.

The scheduler will reply back to you by e-mail either to confirm or to suggest an alternative date and time if we cannot accomodate that visit. You will also receive a copy of your schedule request by email.

*** For CANCELLATIONS, we have a simplified form (which may be used for in and outpatients), please click HERE.

For CHANGES, please type "CH" and explain changes in the Visit #/Test section.


 

Scheduler Information:

Name:           
Email Address:  

 


Patient Visit Information:

Visit Date
(mm/dd/yy)
Protocol
#
Patient's Name
(Last, First)

Time
In

Time
Out

Visit #/Test Location MRN DOB P.I. Physician covering visit

 

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