About Your Trial
By providing the information here below and submitting this electronic form, you are authorizing Medinexo, to use the information provided with the purpose of performing a Medinexo® Network assessment to identify potential sites and populations that could be prospect participants in your Trial . Medinexo® will not contact the prospect sites or share any information about your Trial with Medinexo® Member Sites without your prior consent. 
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Email *
Your Name *
Company Name *
Phone Number *
Study Name *
Study Type *
Phase *
 # of Sites
 *
# of Patients per site
 *
Enrollment period (number of months)
 *
Study Duration (number of months)
 *
Target Region *
Required
Specific Countries
Therapeutic Area *
Please Specify other Therapeutic Area
Intervention Model
The general design of the strategy for assigning therapies or intervention being studied to participants in a clinical study. Types of intervention models include single group assignment, parallel assignment, cross-over assignment, and factorial assignment.
Primary Endpoint(s)
Is the trial aimed at  evaluating a medical, surgical, or behavioral intervention?
Study Start Date *
MM
/
DD
/
YYYY
Study Completion Date *
MM
/
DD
/
YYYY
Need a Diversity Assessment for your Trial?
Are you representing a CRO?
If you are representing a CRO, is this trial already under agreement?
Required
A copy of your responses will be emailed to the address you provided.
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