_________________________________________________________________
Collaborator Name    Title

____________________________
Email Address   
 
_____________________________________________
Clinic Name

_____________________________________________
University

_________________________________________________________________
Delivery Address for Fed Ex

______________________________________________
PO Box

_________________________________________________________________
City     State or Province     Zip code

____________________________________
Country

_________________________________________________________________
Phone number with area code:    Fax number


Lipid Clinic Questions:

______________________________________
Medical Director:

________________________________________________________
Clinic Manager:     Phone:

Does a dietician routinely see each new patient?   Yes ð   No ð
Does your clinic accept pediatric patients?    Yes ð   No ð
Does your clinic conduct research or clinical trials?   Yes ð   No ð
Does your clinic have an LDL-apheresis machine?   Yes ð   No ð



Lab Facilities
Does your lab have the following capabilities:
Lipid Analysis (TC, TG, HDL)?  Yes ð   No ð
Standardized with CDC?   Yes ð   No ð
Ultracentrifugation?   Yes ð   No ð
Apolipoprotein E ?     Yes ð   No ð
Apolipoprotein assays?  Yes ð   No ð

Specify which:   _________________________________________
Cell culture studies, fibroblasts? Yes ð   No ð
   
            Specify which:   _________________________________________
Molecular biology techniques? Yes ð   No ð
 
Specify which:   _________________________________________
Any other special tests?  Yes ð   No ð 
Specify which:   _________________________________________
 
Please list your phone number for patients to make an appointment:________________________

Please list your clinic hours:

________________________
Monday
________________________
Tuesday
________________________
Wednesday
________________________
Thursday
________________________
Friday
________________________
Saturday


Please fax form to MEDPED at FAX:  801-581-5402

Or mail to:
Susan Stephenson, Pharm.D.
MEDPED Coordinating Center
University of Utah
410 Chipeta Wy, Room 161
Salt Lake City, UT 84108