Clinical Investigators and Translational Research Scientists Sample Application Form
Thank for you interest in Micronbrane Medical.

Important: This program intended for researchers to request and receive a complimentary sample of our kit and for you to provide your feedback after the evaluation. It is not intended to provide materials for clinical use or for data generation for publication. You agree not to disclose or publish data obtained by using samples. However, after evaluation, if you decide to use our products in your  research, we are happy to help. Micronbrane Medical products provided to you in this program are for research purposes only. 

By submitting this form you agree:

  • Not to use the trial products in a clinical setting and will not used to direct or influence patient care.
  • To share the results of your trial with Micronbrane Medical. 
  • Micronbrane Medical has, and retains, all rights to all intellectual property, inventions and discoveries including any that may result from the trial.
  • We may, at our discretion, use the blinded, collated or aggregated data from your trial for product development and/or marketing purposes for any future potential disclosure and or publication.
We agree to not disclose you or your institution’s participation in the program, or the results obtained from your evaluation.  Thank you! 

Email *
First and Last Name *
Title/Role
Institution Name *
Institution Receiving Address 
Phone Number 
Clear selection

Your proposed use of Micronbrane Medical's products. Please provide a brief description of how you would test and what desired endpoints would be.

 *
What kinds of samples are you testing (whole blood, plasma, serum, BALF, CSF, etc.)? *
What Micronbrane Medical products you are interested in evaluating?
 *
Please check all the equipment and consumables you have in your Lab. *
Required

I fully understand and comply with all the requirements and conditions above and confirm that  the information provided herein is accurate, correct and complete. 

 *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of 康博醫創股份有限公司. Report Abuse
Google Forms