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
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.