TDD Sponsor Request Form – Medinexo

Medinexo
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Medinexo
About-us
For Healthcare Providers
For Sponsors
Login / Register

Therapeutic Development Data

Sponsor Request Form

Full Name

Company Name

Phone Number

Email Address

Project Type

Type of Real World Data Study

ProjectDescription

Inclusion CriteriaProjectDescription

ExclusionCriteriaProjectDescription

Region

Patients

Estimated USD Per Case Budget

Estimated USD Per Case Budget

AdditionalRequirements

RequiredData

Demographic data (e.g., date of birth, gender, race, ethnicity) Conditions (e.g. ICD9 or ICD10 codes) Visits / Encounters (e.g., visit date, visit type) Procedures / Interventions (e.g., CPT or HCPCS codes or surgery names) Medications (e.g., drug name, dosage, formulation, NDC code) Reports (e.g., Radiology Reports, Clinical Notes) Lab Results Imaging Studies Genomics Claims Other (please specify)

DeliveryTime

Comments

DataStartDate

DataEndDate

OtherDataSpecs

Questions