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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
First
Last
2. Practice Name
3. Practice Address
4. Contact Number
5. Contact Email
6. Contact Preference
Phone
Email
Text Message
7. Professional Designation
MD
MD/PhD
DO
PhD
NP
8. Specialty
9. Board Certification and Membership
10. Years in Practice
< 5 Years
5-10 Years
11-15 Years
16-20 Years
> than 20 Years
11. Type of Practice
Solo Practice
Group Practice (2-4 Providers)
Group Practice (more than 4 Providers)
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)?
Yes
No * if NO, proceed to Question 16
13. Which category best describes the research conducted? (Select all that apply)
Investigator Initiated
Academic Sponsored (e.g., NIH, DOD, etc.)
Pharmaceutical or Biotech Industry Sponsored
14. How many industry-sponsored Phase II-IV clinical trials have you conducted as a Principal Investigator?
None
1-5 Studies
6-10 Studies
> than 10 Studies
15. How many industry sponsored Phase II-IV clinical trials have you served as a Sub-Investigator?
None
1-5 Studies
6-10 Studies
> than 10 Studies
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
Aneurysms (cardiac)
Angina pectoris
Atherosclerosis
Atrial Fibrillation
Blood Clots
Cardiac Catheterization
Cardiac Ischemia
Cardiomyopathy
Chest Pain
Congenital Heart Disease
Congestive Heart Failure
Coronary Artery Disease
Deep Vein Thrombosis
Dyslipidemia
Dysrhythmias
Heart Attack
Heart Defects
Hypertension
Metabolic Syndrome
Mitral Valve Regurgitation
Myocardial Infarction
Coronary Artery Disease
Obesity
Pace Maker
Peripheral Vascular Disease
Pulmonary Embolism
Stress
Stroke
Syncope
Thrombosis
Vascular Diseases
Other (Specify):
CLINICAL TRIALS IN DERMATOLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Acne
Actinic Keratosis
Atopic Dermatitis
Bacterial Infections
Burns
Contact Dermatitis
Congenital Skin Diseases
Herpes Simplex Infections
Hyperhidrosis
Herpes Zoster Infections
Herpetic Neuralgia
Hives (Urticaria)
Ichthyosis
Impetigo
Pressure Ulcers
Psoriasis and Psoriatic Disorders
Rosacea
Scleroderma
Seborrhea
Skin Cancer
Shingles
Skin Ulcers
Staphylococcal Skin Infections
Stasis Dermatitis
Wounds
Other (Specify):
CLINICAL TRIALS IN ENDOCRINOLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Diabetes Complications
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Diabetic Neuropathy
Diabetic Retinopathy
Endometriosis
Hormone Deficiencies
Hormone Replacement Therapy
Human Growth Hormone
Hypoglycemia
Hypogonadism
Leiomyomas
Lymphedema
Malignant Adenoma
Menopause
Metabolic Syndrome
Obesity
Pancreatitis
Parathyroid Disorders
Pituitary Disorders
Thyroid Disorders
Uterine Fibroids
Other (Specify):
CLINICAL TRIALS IN GASTROENTEROLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Achalasia
Barrett’s Esophagus
Bowel Dysfunction
Celiac Disease
Chronic Diarrhea
Constipation
Crohn’s Disease
Digestive System Neoplasms
Esophageal Disorders
Functional Dyspepsia
Gastroenteritis
Gastroesophageal Reflux Disease
Hepatitis B
Digestive System Neoplasms
Esophageal Disorders
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Mucositis
Pancreatic Disorders
Rectal Disorders
Ulcerative Colitis
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Other (Specify):
CLINICAL TRIALS IN NEPHROLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Acute Kidney Injury (AKI)
Alport Syndrome
Atypical Hemolytic Uremic Syndrome
Chronic Allograft Injury
Chronic Hepatitis C Virus
Chronic Kidney Disease
Cystinosis
Diabetic Nephropathy
Diabetes Related Renal Disease
Dialysis/Hemodialysis Vascular Access
End Stage Renal Disease
Hyperkalemia
Renal Fibrosis
Renal Function
Other (Specify):
CLINICAL TRIALS IN NEUROLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
ALS
Alzheimer’s Disease
Autism
Brain Aneurysm
Brain Disorders
Brain Injuries
Carpal Tunnel Syndrome
Cognition
Down Syndrome
Essential Tremor
Huntington’s Disease
Leg Cramps
Multiple Sclerosis
Muscular Dystrophy
Neuropathy
Parkinson’s Disease
Peripheral Nervous System
Polyneuralgia
Pompe Disease
Post Herpetic Neuralgia (PHN)
Pseudobulbar Affect (PBA)
Restless Leg Syndrome (RLS)
Seizures (Epilepsy)
Shingles
Spasticity
Spinal Cord Injuries
Stroke
Stroke – Acute Ischemic
Tourette Syndrome
Other (Specify):
CLINICAL TRIALS IN PULMONOLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Acute Respiratory Distress Syndrome
Asthma
Chronic Bronchitis
Chronic Cough
Chronic Obstructive Lung Disease
COPD
Cystic Fibrosis
Emphysema
Idiopathic Pulmonary Fibrosis
Influenza
Lung Disease
Lung Injury
Pleural Diseases
Pulmonary Arterial Hypertension
Pulmonary Fibrosis
Recurrent Respiratory Papillomatosis
Respiratory Failure
Sleep Apnea Syndromes
Upper and Lower Respiratory Tract Infections
Other (Specify):
CLINICAL TRIALS IN UROLOGY
Please check ✔ all that correspond to your interest
Please check ✔ all that correspond to your interest
Benign Prostate Hyperplasia
Bladder Disorders
Bladder Pain (Interstitial Cystitis)
Calculi
Erectile Dysfunction
Overactive Bladder
Premature Ejaculation
Prostate Disorders
Sexual Dysfunction (Male)
Sexually Transmitted Disease, Male
Spermatogenesis
Testicular Disorders
Urinary Incontinence
Urinary System Neoplasms
Other (Specify):
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?
Yes
No
If Yes…
Participation as a Principal Investigator and/or Sub-Investigator
Participation as a Referring Physician
Name
This field is for validation purposes and should be left unchanged.
Δ
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