PART THREE
Research Protocol
Adult Onset Diabetes in Men
Treatment with Testosterone

RETURN THESE MATERIALS TO:
Edward M. Lichten, M.D.P.C.
180 East Brown Street
Birmingham, MI 48009

248.593.9999    Fax: 248.644-0066    Email: drlichten@yahoo.com

Project Number:609-97 Providence Hospital, Southfield, Michigan


PART-3: REQUEST TO PARTICIPATE AS A REFERRING PHYSICIAN

PLEASE COMPLETE THE INFORMATION IN THE BOXES BELOW:

PHYSICIAN NAME AND ADDRESS
LAST NAME_____________________
FIRST NAME_____________________
INITIAL_____________________
COMPANY_____________________
ADDRESS1_____________________
ADDRESS1_____________________
CITY_____________________
STATE_____________________
ZIPCODE_____________________
PHONE NUMBER_____________________
FAX NUMBER_____________________
EMAIL_____________________
MEDICAL LICENSE (STATE?)_____________________
LICENSE NUMBER_____________________
EXPIRES_____________________
DEA NUMBER_____________________
EXPIRES_____________________
ANY FELONY CONVICTIONS (YES/NO)_____________________
ANY STATE LICENSING ISSUES {YES/NO)_____________________
ACTIVE HOSPITAL PRIVILEGES (YES/NO)_____________________

I, _______________________________, residing at (address)_________________________
_________________________________ request to participate in the research protocol entitled "Treatment of Men with Adult Onset Diabetes with Testosterone." By signing below, I certify that I am a duly licensed physician in the state of ________________. I have no felony convictions and am in good standing with my hospital, local and state medical boards. I have an unrestricted DEA license to order testosterone. And, if given an authorization number and protocol to continue, I will follow the instructions of the research study and notify Dr. Lichten in writing of any complications or difficulty with this study.

_________________________________(signature)

_________________________________(witness signature)

____________________(date)


Overview: