TICH-3 - participant contact details

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TICH-3

TICH-3 – Tranexamic acid for IntraCerebral Haemorrhage 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)/clinic: (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:

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