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TICH-3
TICH-3 –
T
ranexamic acid for
I
ntra
C
erebral
H
aemorrhage
3
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TICH-3 participant contact details
Form submitted by:
Participant's initials:
TICH-3 trial number:
Surname:
Forename(s):
Middle initials:
Permanent address:
Post code:
Country:
Follow-up telephone number:
Temporary residence:
Please check that the
permanent
residence
has been given above.
Alternate telephone number:
Email address:
Date of birth:
/
/
(dd/mmm/yyyy)
NHS/CHI/H+C number:
Hospital number:
(
not
centre ID)
Name of hospital ward(s):
(
not
hospital name)
GP title/name:
GP practice name:
GP address:
GP post code:
GP telephone:
Next of kin name:
Next of kin relationship:
Next of kin address:
Next of kin telephone:
Next of kin email:
Close relative/friend name:
Close relative/friend relationship:
Close relative/friend address:
Close relative/friend telephone:
Close relative/friend email:
Comments:
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