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Scientific Support Liaison Site Visit Request

Name(Required)

First Last Title

Requestor Cell Number(Required)

Visit Location (city/area):(Required)

Location of visit – If MSL can attend via WebEx or conference call please indicate

Sites Being Visited:(Required)

Name of clinic(s)

Will this be a virtual presentation?(Required)

Yes

Date of meeting(Required)

Time of meeting

Primary doctors to be visited?(Required)

Name of OPs to be visited

Background on physician as it relates to Caris(Required)

Number/names of others from Caris attending(Required)

Number of individuals who will be visited/attending

Number/names of others from site attending(Required)

Number of individuals who will be visited/attending

Is the appointment confirmed with the site?(Required)

Is there an appointment/pre-arranged meeting?

Yes

MSL(Required)

Have you spoken with an MSL regarding this meeting? If so, who?

Purpose of visit(Required)

Please provide any detailed background info, goals of the meeting, and what you would like the MSL to prepare. This should minimize the need for a lengthy pre-call in most cases.

Will there be a formal presentation?(Required)

Is this a formal presentation or a general meet and greet?

Yes

If yes, how long should the MSL's portion of the presentation be?

Will this meeting be tumor type focused? If so, on which one?(Required)

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Comments

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

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Scientific Support Liaison Site Visit Request