Clinical Research Center

Shepardson 2 - Main Campus

Extended Outpatient (Inpatient) Scheduling Form

You may schedule via this form at any time. If you have questions, please contact Amy Marra, (847-2793), at the CRC, Monday through Friday, 8:00 a.m. to 3:00 p.m.

Extended Outpatient Visit Scheduling Information

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

Also when scheduling visits which have meal schedules, please put the meal times & dates in the note section.

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.

*** NEW *** For CANCELLATIONS, we now have a simplified form (which may be used for outpatients and extended stay visits), please click HERE.

For CHANGES, please type "CH" and explain changes in the comment section.

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

When the volunteer signs the consent form the CRC needs the original copy. The subject may bring it with him/her or you can put it in the campus mail to Joan Bertolet, CRC, Shepardson 2, MCHV Campus.

Scheduler Information:

Email Address:  

Extended Visit Information:

Admission Date (mm/dd/yy)  	        Protocol # 
Patient Name (Last, First)    Admission Time 
Discharge Date (mm/dd/yy)            Discharge Time  
Medical Record Number ***  		              
Date of Birth (mm/dd/yy) 
Study ID (if applicable)  		                
Visit Type/Number 	        P.I.                            

Please put the name of the responsible physician and whether or not he/she has agreed to provide coverage during the admission.

If you do not know who will be covering your admission at this time, be sure to let Joan Bertolet know (7-4874) when you get the information. We need this information by the day before the admission.

Physician covering admission:     Who scheduled the physician? 

*** If the subject does not already have a MRN, please enter the following information:

Subject's address Phone number

Subject's Gender Primary Care Provider

Enter any comments in the space provided below: