Aspira Women's Health



SITE QUALIFICATION FORMSTUDY TITLENAME OF SITE INVESTIGATORINVESTIGATOR EMAILCOORDINATOR NAMECOORDINATOR EMAILSITE ADDRESSINVESTIGATOR INFORMATIONEXPERIENCE IN SPECIALTY in yearsPROFICIENCY IN RESEARCHACADEMIC AFFLIATION (IF APPLICABLE)2 MOST RECENT PUBLICAITONS (IF APPLICABLE)CLINIC INFORMATIONNUMBER OF OBGYN’sNUMBER OF PATIENTSVolume Ova1 (month)Volume GenetiX (month) NUMBER OF TRIALS ONGOINGEXPERIENCE IN CLINICAL TRIALS (PAST)COMPETITIVE TRIALS (ONGOING)YESNOYESNODIAGNOSIS CODEDIAGNOSIS DESCRIPTIONNo. of Patients/MonthZ15.01Genetic susceptibility to malignant neoplasm of breastZ15.02Genetic susceptibility to malignant neoplasm of ovaryZ15.03Genetic susceptibility to malignant neoplasm of prostateZ15.04Genetic susceptibility to malignant neoplasm of endometriumZ15.09Genetic susceptibility to other malignant neoplasmZ15.81Genetic susceptibility to multiple endocrine neoplasia [MEN]C50.__Malignant neoplasm of breastC56.1Malignant neoplasm of right ovaryC56.2Malignant neoplasm of left ovaryC56.9Malignant neoplasm of unspecified ovaryC57.00Malignant neoplasm of unspecified fallopian tubeC57.01Malignant neoplasm of right fallopian tubeC57.02Malignant neoplasm of left fallopian tubeZ85.07Personal history of malignant neoplasm of pancreasZ85.3Personal history of malignant neoplasm of breastZ85.43Personal history of malignant neoplasm of ovaryN83.201Unspecified ovarian cyst, right sideN83.202Unspecified ovarian cyst, left sideN83.209Unspecified ovarian cyst, unspecifiedR19.00Intra-abdominal and pelvic swelling,?nd lump, unspecified siteR19.03Right lower quadrant abdominal swelling, mass and lumpR19.04Left lower quadrant abdominal swelling, mass and lumpR19.09Other intra-abdominal pelvic swelling massCOMMENTS ................
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