PROVIDER INTEREST FORM

INSTRUCTIONS: This form has been designed to capture some basic information regarding your experience with clinical research. The responses you provide will assist Guardian Research in linking your background an experience with growing number of clinical research opportunities received by Guardian Research in select Therapeutic Areas. Opportunities are continuously available for physicians to serve as Principal Investigators (PIs), Sub-Investigators (Sub-Is), or Referring Physician. We thank you in advance for taking the time to complete the form.

A. BACKGROUND INFORMATION

1. Name
6. Contact Preference
7. Professional Designation
10. Years in Practice
11. Type of Practice

B. PAST RESEARCH EXPERIENCE

12. Have you ever conducted a clinical trial where you served as either the Principal Investigator (PI) or Sub-Investigator (Sub-I)?
13. Which category best describes the research conducted? (Select all that apply)
14. How many industry-sponsored Phase II-IV clinical trials have you conducted as a Principal Investigator?
15. How many industry sponsored Phase II-IV clinical trials have you served as a Sub-Investigator?

C. CLINICAL RESEARCH INTEREST

16. Guardian Research has been organized to respond to clinical trial research opportunities in the following eight (8) specific target therapeutic areas:
• Cardiology
• Dermatology
• Endocrinology
• Gastroenterology
• Nephrology
• Neurology
• Pulmonology
• Urology

Below, a table is provided for each of the eight therapeutic areas.
Within each table specific areas of interested are identified corresponding to the therapeutic area.
To ensure timely identification and communication of clinical trial opportunities that emerge from industry sponsors that reflect your specific research interests, please identify in the table that represents your therapeutic area of expertise the specific categories of interest you have for engaging in clinical trials.

CLINICAL TRIALS IN CARDIOLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN DERMATOLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN ENDOCRINOLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN GASTROENTEROLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN NEPHROLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN NEUROLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN PULMONOLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

CLINICAL TRIALS IN UROLOGY

Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest

17. Are you interested in receiving additional information about opportunities to participate with Guardian Research as a Principal Investigator, or Sub-Investigator, or as a referring physician?
If Yes…

This field is for validation purposes and should be left unchanged.

 
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