Request for Quote
Use this form to initiate the LifeGene quoting process. Please note that this form does not generate a quote, but gives LifeGene all the necessary inputs for pricing.
Please enable JavaScript in your browser to complete this form.
General Information
Name (SPOC)
*
*
Email Address
*
Please use your corporate email address.
Phone
*
Designation
*
Division
*
Name (SPOC 2)
*
*
Email Address
*
Please use your corporate email address.
Phone
*
Designation
*
Division
*
LifeGene Contact Email
*
Please enter your LifeGene Business Contact's Email.
Customer Name
*
Sponsor Name
*
If unknown, please enter "UNK."
Protocol or Study ID
*
If unknown, what should we call this study?
Therapeutic Area
Phase or Type of Study
*
Please Choose
Phase 1
Phase 1/2
Phase 2a
Phase 2
Phase 3
Phase 4 (Post-Market)
Registry
Device
Diagnostic
Animal Health
Investigator-Initiated Trial
Consumer Health
Non-Profit
Indication
Study Protocol
Click or drag a file to this area to upload.
Please upload protocol or synopsis.
Anticipated date of first patient in (FPI)?
*
Note: MM/DD/YYYY format. An estimate here is fine.
Anticipated date of last patient out (LPO)?
*
Note: MM/DD/YYYY format. An estimate here is fine.
Number of Enrolled Participants
*
Number of Sites
*
Please provide the country list and languages required.
Duration (in months) from Database Provision to Archive
*
An estimate here is fine.
When is the quote due?
*
Note: MM/DD/YYYY format.
LifeGene Product Selection
Please choose which LifeGene products to include in your pricing request.
EDC
*
Yes
No
Electronic Data Capture
Randomization
*
Yes
No
LifeGene ePRO
*
Yes
No
Dedicated Dashboards, Advanced Reports, Statistics for the Sponsors
eConsent (for patients)
*
Yes
No
CTMS
*
Yes
No
Clinical Trail Management System
Data Integration
*
Yes
No
e.g. With existing EMR/EDC platforms
EC
*
Yes
No
Ethics Committee
Publication Services
*
Yes
No
Medical Imaging
*
Yes
No
ECG, X-Ray, Ultra Sound, Scan Only
Additional Services
Please note that all fields in this section are pre-selected as "no" so you can skip this section if you know that Additional Services are not required.
Will LifeGene provide ongoing Data Management Services?
Yes
No
Will LifeGene provide Biostatistics Services?
Yes
No
Do you need doctor engagement programs as a part of study
*
Yes
No
e.g. Webinars, Print Inputs, Enrolling Chief Investigators of the Molecules to educate Doctors
Additional Notes:
Additional Documents
Click or drag a file to this area to upload.
Any other documents related to this request.
Submit
