Download REQUEST FOR CLINICAL TRIALS PHARMACY

Clinical Trial Pharmacy Department, Alfred Hospital, Commercial Road, Melbourne 3004
Victoria, Australia
Telephone: +61 3 90763309 Fax: +61 3 90763305 Email: [email protected]
REQUEST FOR ALFRED CLINICAL TRIALS PHARMACY COSTING SERVICE
Please email the Study Protocol and this completed Form
To:
Anne Mak, Clinical Trials Pharmacy Manager
Tel: 03 9076 3309
Fax: 03 9076 3305
Email: [email protected]
From: Name/Contact details
Study Title / Protocol Number
/ Alfred Ethics Project No.
Principal Investigator
Department / Unit
Source of Funding
Commercial Sponsor specify name
Investigator Initiated
Others specify funding
Medication(s) / Ancillary
Clinical Supplies provided by
Commercial Sponsor specify name
funded by Investigator
Post Study Completion Drug
Supply
YES, provided by:_________________________
NO, reason:_______________________________
Not Applicable, reason:____________________________
Medication(s) to be dispensed
List of medications
Is Aseptic Preparation service
required?
 YES specify medication
NO
Is Manufacturing /or
Repackaging of medications
required
Is Oncall and/or After-hours
service required ?
 YES specify medication
NO
Are any other services service
required?
Yes specify requirements
No
Yes specify requirements
No
Name and address of person
who will receive Pharmacy
Form CT-05 Version 4 dated 04MAY2016
Clinical Trial Pharmacy Department, Alfred Hospital, Commercial Road, Melbourne 3004
Victoria, Australia
Telephone: +61 3 90763309 Fax: +61 3 90763305 Email: [email protected]
Invoices and/or Investigator’s
Alfred Cost Centre
Costing Letter required by
Date
Please allow at least 7 business working days for Pharmacy to
complete costing. Please note:
 Request will not be considered if this form is
incomplete and information is incorrect.
 If pharmacy receives request after 3pm, the next
working day will be considered as official date of
request.
Form CT-05 Version 4 dated 04MAY2016