{"id":5289,"date":"2021-01-11T19:21:32","date_gmt":"2021-01-12T00:21:32","guid":{"rendered":"https:\/\/www.frontagelab.com\/?page_id=5289"},"modified":"2021-01-11T19:22:43","modified_gmt":"2021-01-12T00:22:43","slug":"central-lab-intake-form","status":"publish","type":"page","link":"https:\/\/frontagelab.com.cn\/en\/central-lab-intake-form\/","title":{"rendered":"Central Lab Intake Form"},"content":{"rendered":"\n<h1 class=\"wp-block-heading\"><\/h1>\n\n\n<script type=\"text\/javascript\">var 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top_label form_sublabel_below description_below validation_below'><li id=\"field_28_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_16\" ><label class='gfield_label gform-field-label' for='input_28_16'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_28_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_26\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_26\" ><label class='gfield_label gform-field-label' for='input_28_26'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_28_26' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_27\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_27\" ><label class='gfield_label gform-field-label' for='input_28_27'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_28_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_28\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_28\" ><label class='gfield_label gform-field-label' for='input_28_28'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_28_28' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_12\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_12\" ><label class='gfield_label gform-field-label' for='input_28_12'>Sponsor Name<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_28_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_13\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_13\" ><label class='gfield_label gform-field-label' for='input_28_13'>CRO Name<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_28_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_46\" ><label class='gfield_label gform-field-label' for='input_28_46'>Study Protocol Number<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_28_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_24\" ><label class='gfield_label gform-field-label' for='input_28_24'>Study Protocol Title<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_28_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_45\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_45\" ><label class='gfield_label gform-field-label' for='input_28_45'>Total Number of Subjects<\/label><div class='ginput_container ginput_container_number'><input name='input_45' id='input_28_45' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_28_43\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_43\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Number of Subjects by Phase (please click the + sign to add an additional row)<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_43_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_43_col_2' class='gfield_list_col_even' \/><col id='gfield_list_43_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th scope=\"col\">Phase<\/th><th scope=\"col\">Number of Subjects<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_43_cell1' data-label='Phase'><input aria-invalid='false'   aria-label='Phase, Row 1' data-aria-label-template='Phase, Row {0}' type='text' name='input_43[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_43_cell2' data-label='Number of Subjects'><input aria-invalid='false'   aria-label='Number of Subjects, Row 1' data-aria-label-template='Number of Subjects, Row {0}' type='text' name='input_43[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)'><img src='https:\/\/frontagelab.com.cn\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style=\"visibility:hidden;\"><img src='https:\/\/frontagelab.com.cn\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_28_42\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_42\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Number of sites by Countries that needs to be supported by Frontage Central Lab:<\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_42_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_42_col_2' class='gfield_list_col_even' \/><col id='gfield_list_42_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_42_col_4' class='gfield_list_col_even' \/><col id='gfield_list_42_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_42_col_6' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">United States<\/th><th scope=\"col\">Europe<\/th><th scope=\"col\">Australia<\/th><th scope=\"col\">Asia-Pacific<\/th><th scope=\"col\">Other<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_42_cell1' data-label='United States'><input aria-invalid='false'   aria-label='United States, Row 1' data-aria-label-template='United States, Row {0}' type='text' name='input_42[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_42_cell2' data-label='Europe'><input aria-invalid='false'   aria-label='Europe, Row 1' data-aria-label-template='Europe, Row {0}' type='text' name='input_42[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_42_cell3' data-label='Australia'><input aria-invalid='false'   aria-label='Australia, Row 1' data-aria-label-template='Australia, Row {0}' type='text' name='input_42[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_42_cell4' data-label='Asia-Pacific'><input aria-invalid='false'   aria-label='Asia-Pacific, Row 1' data-aria-label-template='Asia-Pacific, Row {0}' type='text' name='input_42[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_42_cell5' data-label='Other'><input aria-invalid='false'   aria-label='Other, Row 1' data-aria-label-template='Other, Row {0}' type='text' name='input_42[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_28_30\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_30\" ><label class='gfield_label gform-field-label' for='input_28_30'>Duration of Study: (In Months)<\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_28_30' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_28_32\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_32\" ><label class='gfield_label gform-field-label' for='input_28_32'>First Patient In<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_32' id='input_28_32' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_28_32_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_28_32_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_28_32' class='gform_hidden' value='https:\/\/frontagelab.com.cn\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_28_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_47\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >What areas of service will be needed (please check all that apply):<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_28_47'><li class='gchoice gchoice_28_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Logistic Service'  id='choice_28_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_1' id='label_28_47_1' class='gform-field-label gform-field-label--type-inline'>Logistic Service<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Central Lab Testing Service'  id='choice_28_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_2' id='label_28_47_2' class='gform-field-label gform-field-label--type-inline'>Central Lab Testing Service<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Flow Cytometry'  id='choice_28_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_3' id='label_28_47_3' class='gform-field-label gform-field-label--type-inline'>Flow Cytometry<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Histology\/Pathology\/Fresh Tissue or Paraffin Block Processing'  id='choice_28_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_4' id='label_28_47_4' class='gform-field-label gform-field-label--type-inline'>Histology\/Pathology\/Fresh Tissue or Paraffin Block Processing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Biorepository\/Specimen Storage'  id='choice_28_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_5' id='label_28_47_5' class='gform-field-label gform-field-label--type-inline'>Biorepository\/Specimen Storage<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='PBMC Processing'  id='choice_28_47_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_6' id='label_28_47_6' class='gform-field-label gform-field-label--type-inline'>PBMC Processing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.7' type='checkbox'  value='Cell Free DNA Processing'  id='choice_28_47_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_7' id='label_28_47_7' class='gform-field-label gform-field-label--type-inline'>Cell Free DNA Processing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_28_47_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.8' type='checkbox'  value='Other'  id='choice_28_47_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_28_47_8' id='label_28_47_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_28_48\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_48\" ><label class='gfield_label gform-field-label' for='input_28_48'>If other is chosen for the prior question, please specify what type of service will be needed:<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_28_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_28_49\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_28_49\" ><label class='gfield_label gform-field-label' for='gform_browse_button_28_49'>Please upload the most up to date study protocol:<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_28_49' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_28_49&quot;,&quot;container&quot;:&quot;gform_multifile_upload_28_49&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_28_49&quot;,&quot;filelist&quot;:&quot;gform_preview_28_49&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/frontagelab.com.cn\\\/?gf_page=93b798850cdad1f&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/frontagelab.com.cn\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/frontagelab.com.cn\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed 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