Clinical Trial and Research Study Request Form

Requestor Information

Name:

Company: (Optional)

Address Line 1:

Address Line 2: (Optional)

City:

State or Province:

US and Canada:

Other:

Zip or Postal Code:

Country:

Email Address: (Your email address will not be released to any third party marketer)

Telephone: (Optional)

Is billing info the same as above?

Yes No

Name:

Company: (Optional)

Address Line 1:

Address Line 2: (Optional)

City:

State or Province:

US and Canada:

Other:

Zip or Postal Code:

Country:

Email Address: (Your email address will not be released to any third party marketer)

Telephone: (Optional)

Guilford Press Title Information

Book Title:

Author/Editor(s):

ISBN:

Year of Publication:

Page Numbers:

Scale or Assessment Name:

How Guilford Material will be Used

Protocol/Trial ID:

Phase:

Location:

Languages:

Number of Sites:

Number of Subjects:

TOTAL Administrations:

Duration of Study: from: to:

Method of Distribution: (Print, electronic, or other)

Anticipated Attendance / # Copies:

Number of Facilitators, Administrators, & Project Leads:

Format/Media requested (fill out all that apply)

(Optional)

Print only (quantity):

Electronic: Yes No

Details for Electronic Administration:

Other Comment

(Optional)

Supporting Documents

Allowed file types: pdf, doc, docx, txt, rtf, odt. Up to 5 files allowed, with maximum combined file size of 5 MB.

Free Shipping on Online Orders!

Applies only to prepaid online orders from US customers.

Packages sent via USPS Media Mail. You may choose to pay for rush shipping instead.

We've also reduced shipping charges to Canada to a flat $9.00 per order. Packages sent via CanPar.

You may return Guilford books (undamaged) within 30 days of receipt for a full refund.

For bulk orders, please contact: info@guilford.com