DIRECTIONS: To request an out-patient appointment for a research participant complete and submit this form to the Central Scheduling-Research team at . Submit this Form at least 48 hours prior to the date/time of the appointment request. Research appointment requests are processed M-F, 8-4:30. Requests received immediately before the date/time being requested cannot be accommodated. Appointment confirmation is routinely provided via email. If the Submitter has not received email confirmation 24 hours prior to the requested appointment, please resubmit the request. If you have questions: Contact with questions specific to scheduling research visits. Contact the Office of Grant Administration at with research related questions. You may also refer to the Patient Research Visits” Tip Sheet for guidance. “Managing NOTE: Appointments for radiology services are requested by submitting the to the CT Scheduling team. All Forms & Tip Sheets can be obtained at the . The asterisks (*) denotes required information Research Study & Contact Information Grady Plan Code* (e.g. E600. Refer to the study’s ROC Approval document) Ordering Clinician* PI Name* Requestor Name* Requestor Phone Number * Email* Appointment Request Information Appointment Date* (mm/dd/yy) Appointment Time* NOTE: It is the responsibility of the PI/designee to provide the confirmed date, time and appointment location to the patient. Patient Demographic Information NOTE: A patient MUST be into the referenced study in Epic prior to transmitting this form “enrolled” Last Name* First Name* Middle Initial Date of Gender (mm/dd/yyyy) Medical Record Number* Social Security Number Check, if a new MRN is required. *To obtain a new MRN, provide the patient’s full name, date of birth, mailing address and phone number. Patients cannot be scheduled without the information required to obtain an MRN. Language Address City State Zip Code Phone Number ** Remember to submit the Research Patient Tracker Form after each research visit.
DIRECTIONS: To request an out-patient appointment for a research participant complete and submit this form to the Central Scheduling-Research team at . Submit this Form at least 48 hours prior to the date/time of the appointment request. Research appointment requests are processed M-F, 8-4:30. Requests received immediately before the date/time being requested cannot be accommodated. Appointment confirmation is routinely provided via email. If the Submitter has not received email confirmation 24 hours prior to the requested appointment, please resubmit the request. If you have questions: Contact with questions specific to scheduling research visits. Contact the Office of Grant Administration at with research related questions. You may also refer to the “Managing Patient Research Visits” Tip Sheet for guidance. NOTE: Appointments for radiology services are requested by submitting the to the CT Scheduling team. All Forms & Tip Sheets can be obtained at the . The asterisks (*) denotes required information Research Study & Contact Information Grady Plan Code* (e.g. E600. Refer to the study’s ROC Approval document) Ordering Clinician* PI Name* Requestor Name* Requestor Phone Number * Email* Appointment Request Information Appointment Date* (mm/dd/yy) Appointment Time* NOTE: It is the responsibility of the PI/designee to provide the confirmed date, time and appointment location to the patient. Patient Demographic Information NOTE: A patient MUST be “enrolled” into the referenced study in Epic prior to transmitting this form Last Name* First Name* Middle Initial Date of (mm/dd/yyyy) Gender Medical Record Number* Social Security Number Check, if a new MRN is required. *To obtain a new MRN, provide the patient’s full name, date of birth, mailing address and phone number. Patients cannot be scheduled without the information required to obtain an MRN. Language Address City State Zip Code Phone Number ** Remember to submit the Research Patient Tracker Form after each research visit.
OGA-Res-Patient_Pre-Registration-v03.2018.docx