You may schedule via this form at any time. If you have questions, please
contact Amy Sylvia, (847-2793), at the CRC, Monday through Friday, 8:00 a.m.
to 3:00 p.m.
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 in and outpatients),
please click HERE.
For CHANGES, please type "CH" and explain changes in
the comment section.
No patient 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 patient may bring it with him/her or you can put it in the campus mail
to Joan Bertolet, CRC, Shepardson 2, MCHV Campus.
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)
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
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?
Enter any comments in the space provided below: