First name *

Last name *

Email address *

Phone number *

Company name *

Website URL *

Check if you have a tax exemption certificate

Address line 1 *

Address line 2

City / locality *

State / region

Postal code *

Country *

Billing address is the same as shipping address

Address line 1

Address line 2

City / locality

State / region

Postal code

Country

ClinicalTrials.gov Listing

Institution/Organization Website *

Formal Title of Trial/Study *

Primary disease state or area of focus *

Other (please specify)

Will you use REDCap to collect study data? YesNoNot sure

Describe your study design and protocol, including objectives, intervention or control groups, testing frequency (glucose and/or ketones), and key outcome measures. *

Number of study locations *

Number of participants in the study *

Number of research team members *

Estimated recruitment start date *

Expected trial or study start date *

Expected trial or study complete date *

Please describe the expected study duration *

Have you allocated a budget for devices and technical needs? * YesNoNot SureApplying for funding

Will participants be enrolled in cohorts or on a rolling basis? *

What type of organization do you represent? *

Please describe your onboarding approach. *

Other (please specify)

Is the study decentralized or site-based? * DecentralizedSite-basedHybrid

Please describe your product distribution plan *

Principal Investigator Full Name *

Principal Investigator Title *

Preferred method of payment *

Do you require a data collection platform? * YesNoNot sure

What EHR/EMR system do you use?

Other (please specify)

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