Request Form For Clinical Trial Supplies

Please complete all relevant sections in order to expedite your request.

By submitting your request you are consenting to Smartway CTS using the information on the request form to source and supply the product(s) and will not be held liable directly or indirectly for any loss sustained.

Name of Requester (required):   
Address of requester (required):   
E Mail (required):   
Phone No. (required):   
Date of Request (required):   
Name and Address of Final User (required):   
Name of Product (required):   
Formulation/Strength/Pack Size (required):   
Total Number of Packs Required (required):   
Same Batch?(required):     Yes No
Shelf Life Requested(Years) (required):   
Date Required By (required):   
Please specify if split delivery required with dates (required):   
Use of Product (required):     Non–Interventional Study
 Observational Study
 Comparator Study
 Examination, Testing or Analysis
 At an investigational Site Outside EU /EEC
 Any Other Specified Use (must fill below box)

 Specified Clinical Trial ( must complete sections below)
Title of Trial:   
Phase (Please Indicate):   
EudraCT Number:   
Classification of Drug in Study:     IMP
 None IMP
Will the product be used according to its Marketing Authorisation:     Yes  No
If Not, What Dose (Please indicate):   
Study Sponsor (for each country if applicable):   
Countries in Which the Study Will Be Conducted:   
Estimated Number of Patients and Sites by Country:   
Estimated Drug Quantities by Country:   
Emergency 24 hour contact number for recall/safety notices:   
Additional Information if Any: