Intermacs Application

Hospital Information
Hospital Name
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Hospital Address
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Patient Population (check all that apply)
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Primary Contact (Site Administrator)
Contact Name
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Contact Address
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Contact Phone Number
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Contact Fax Number
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Contact Email Address
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Principal Investigator Information
Principal Investigator Name
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Principal Investigator Address
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Principal Investigator Phone Number
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Principal Investigator Fax Number
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Principal Investigator Email Address
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Contact Name
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Contact Phone Number
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Contact Email Address
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Financial Contact (Required for Invoicing)
Contact Name
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Contact Phone Number
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Contact Email Address
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Please type in the following characters:*
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