Date of visit: OUTPATIENT VISIT REQUEST and DATA FORM Email completed form to Yale Center for Clinical Investigation (Robert Sherwin, MD Program Director) CSRU 2 Church St So Suite 401 IF YOU HAVE ANY QUESTIONS, PLEASE CALL 203 785 7421 fax 203 785 7450 Visit Information Study staff information: HIC number: Visit #: PI name: Expected time of arrival: PI phone: Expected length of appointment (total): Hrs min Responsible MD (if applicable): Type of visit : Responsible MD phone: Screening hrs__ min__ Screening w/blood hrs __ min __ Coordinator/RA name: Phlebotomy only min__ ECG hrs __ min__ Coordinator/RA phone OGTT hrs __ min__ MMTT hrs __ min__ Has patient signed consent yes no : describe min__ hrs__ Patient information MR number: Ethnicity: Last Name: Race: First Name, Middle Initial: Birth Date: Does the patient speak English? Is the patient deaf or hearing impaired? Yes No Yes No if no, language spoken Place of Birth (City, State, Country): Is assistance needed for communication? Yes No Gender: Height (in) Weight (lbs.) Address (Street/PO Box, City, State, Zip Code): Phone number: Home: Cell: Work: In Case of Emergency: Name of local relative or friend: Relationship to subject: Phone: Home: Cell: Form submitted by Date submitted _
Date of visit: OUTPATIENT VISIT REQUEST and DATA FORM Email completed form to Yale Center for Clinical Investigation (Robert Sherwin, MD Program Director) CSRU 2 Church St So Suite 401 IF YOU HAVE ANY QUESTIONS, PLEASE CALL 203 785 7421 fax 203 785 7450 Visit Information HIC number: Visit #: Expected time of arrival: Expected length of appointment (total): Hrs min Type of visit : Screening hrs__ min__ Screening w/blood hrs __ min __ Phlebotomy only min__ ECG hrs __ min__ OGTT hrs __ min__ MMTT hrs __ min__ : describe hrs__ min__ Study staff information: PI name: PI phone: Responsible MD (if applicable): Responsible MD phone: Coordinator/RA name: Coordinator/RA phone Has patient signed consent yes no Patient information MR number: Ethnicity: Last Name: Race: First Name, Middle Initial: Birth Date: Does the patient speak English? Yes No if no, language spoken Is the patient deaf or hearing impaired? Yes No Place of Birth (City, State, Country): Is assistance needed for communication? Yes No Gender: Height (in) Weight (lbs.) Address (Street/PO Box, City, State, Zip Code): Phone number: Home: Cell: Work: In Case of Emergency: Name of local relative or friend: Relationship to subject: Phone: Home: Cell: Form submitted by Date submitted _