MediCapital Rent
Collection request
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Collection request
Equipment info
Kind
*
Centrifuges
Cooling equipment
ECG
Pumps
Scales
Incubators
Temperature Loggers
Storage
Other
Number of units
*
Serial No(s)
*
Kind
Centrifuges
Cooling equipment
ECG
Pumps
Other
Number of units
Serial No(s)
Kind
Centrifuges
Cooling equipment
ECG
Pumps
Other
Number of units
Serial No(s)
Study info
Study nr.
Study code / protocol (Sponsor)
Centre nr.
*
Location details
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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