Patient form

Validation sheet /
Expense reimbursement

Management of patient expense reimbursement during the clinical trial, in accordance with Royal Decree 1090/2015 of 4 December, Art. 3h.

Reimbursement request

Fill in the form with the study details and the expenses incurred during the visit. Fields marked with * are required.

    HOSPITAL OR CENTER VALIDADOR

    VALID EXPENSES FOR THE HOSPITAL OR VALIDATOR CENTER

    Own vehicle

    YesNo

    Total Km

    Transport

    YesNo

    Per diem

    YesNo

    Lodgement

    YesNo

    Others

    YesNo

    Fixed expenses per visit

    YesNo

    Accompanying expenses

    YesNo

    Amount of Tickets and Amount

    *Required fields