Site Tools & Forms

For physicians using EMR

If you are currently using an EMR platform, please consult your respective EMR vendor to find out how to download and start using e- OBRI data collection forms

For Physicians without EMR

The following forms are necessary for site participating sites without EMR. Please fax OBRI forms to the central data management office at  1-888-757-6506.

Consent, Enrollment & Withdrawal Forms

Office Consent Form (PDF)
Patients are required to sign the  office consent to release personal information and be contacted by  OBRI.

Daily Fax Sheet (PDF)
Please record contact information for  newly referred patients and faxed to OBRI

Patient Information Package (Request Online)
Please provide this package to  each new patient who provides office consent. Request for this is available on-line:  Site Request for Supplies form.

Enrollment Form (PDF)
The enrollment form is to be completed  once for each newly referred patient

Withdrawal Form (PDF)
The withdrawal form is to be completed when a patient withdraws from OBRI, for reasons including patient choice, lost-to-follow-up, and/or death.

Study Assessment & Medication Forms

Study Assessment Form (PDF)
The Study Assessment Form is to be completed at every patient -physician visit.

Medication form (PDF)
The Medication Form is to be updated at every patient -physician visit.

Site Request for Supplies

Please submit the online Site Request for Supplies Form to request patient packages, brochures, posters and other study material.