<p> CTSI Clinical Research Center SFVA</p><p>VISIT Reservation Form</p><p>Study Information Date sent to CCRC: (mm/dd/yy) CHR # (between dashes): Participant Information Grant Management: NCIRE UCSF PID: VA Other/NA Pt Initials: Consent: Scanned into CPRS Account Number: Copy provided at visit Please remember to register participant with member services</p><p>Principal Investigator Research Associate Name: Name: Office Phone: Office Phone: Pager: Pager: Email: Email: </p><p>Date of Visit Start Time Visit # Nursing tasks, other procedures (mm/dd/yy) (military) 1 Select task Other: </p><p>2 Select task Other: </p><p>3 Select task Other: </p><p>4 Select task Other: </p><p>5 Select task Other: </p><p>* Please Call Henry Holdt at (415) 750-6670 for same day appointments</p><p>Other requests/instructions: </p><p>Please hand-deliver to Henry Holdt in Bldg 203 Room 1A-14 or fax to (415) 750-0502. A confirmation email will be sent to the RA email address above. Approval and Entered [ ] Verified Active Study [ ] Nurse Manager [ ] Schedule [ ] RA Confirmation Initials:___</p>