Clinical Trial Application

Specialist Radiology is committed to providing high-quality diagnostic imaging, accurate reporting and responsive support.

If you have any trouble completing this application, please email clinicaltrials@specradgroup.com.au

CLINICAL TRIAL DETAILS

Clinical Trial Name

Trial Acronym

Protocol

Sponsor

Estimated Study Completion Date

Do you require Specialist Radiology to complete a Pre-Trial Survey? *

Yes No

APPLICANT DETAILS

Clinical Trial Site Name

ABN

Postal Address

Site Principal Investigator

Mobile Number

Email Address

Contact Phone Number

IMAGE & REPORT DETAILS

Preferred Specialist Radiology Imaging Location

Imaging Requirements

Provision of Imaging

CD Data Transfer

De-identified Imaging

Yes No

Specialised Reporting Requirements

INVOICE MANAGEMENT

Invoice Method

Post Email

Invoice Details

DOCUMENT UPLOAD

Please attach the Study Protocol / Image Aquisition Guidelines and other relevant documents

Additional Comments

Please note: Correspondence, service agreements and imaging request forms will be emailed to the clinical trial coordinator unless otherwise specified in the Additional Comments field above.

Send me a copy of my responses

Clinical Trial Application

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