MediCapital Rent
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Collection request
Equipment info
Kind
*
Centrifuges
ECG
Freezers
Incubators
Pumps
Refrigerators
Scales
Storage
Temperature Loggers
Other
Number of units
*
Serial No(s)
*
Kind
Centrifuges
Cooling equipment
ECG
Incubators
Pumps
Scales
Storage
Temperature Loggers
Other
Number of units
Serial No(s)
Kind
Centrifuges
Cooling equipment
ECG
Incubators
Pumps
Scales
Storage
Temperature Loggers
Other
Number of units
Serial No(s)
Study info
Study nr.
Study code / protocol (Sponsor)
Centre nr.
*
Location details(e.g. at the reception desk)
IMPORTANT: Please be very specific with the location where the unit has to be picked up. e.g. Floor, Department, Room, Route, etc.
Hospital / Institute
*
Department
Address
*
Postal code
*
City
*
State
Country
*
Tel. of the contact at the site
*
Fax
Contact person at the site
*
E-mail address
*
CRA / monitor details
Name
*
Tel
E-mail address
Customer information
Company name
*
Ordered by (name)
*
E-mail address
*
Billingcode
Suggested pickup Date
Remark pickup date
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Name
*
Phone Number
*
Company
*
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