Other Requests - Publication, Reproduction, Research

Other Requests - Publication, Reproduction, Research

All fields with an asterisk (*) are mandatory
Email
example@example.com
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Which tool(s) are you requesting permission to use?*

Palliative Performance Scale Version 2 (PPSv2)Bowel Performance ScaleRespiratory Congestion Scale10 Steps for Better PrognosticationOther
Please specify what language you would like for the PPSv2:*
Do you wish to receive a PDF of the clinical tool(s) selected above?*

YesNo
Would you be using the tool(s) for profit?*

YesNo
How would you be using the tool(s)?*

Book (Printed or electronic)Website displayBrochures/PostersConference/PresentationCourse contentElectronic Medical Record (EMR)Printed clinical formJournal articleTranslationClinical trialOther
If you selected "Other" please specify how you would like to use the tool*
Should the results of your study be published, we require that only the sample version of the tool be sent to publication (included in the release after consent)*

I agree to this condition
If you are requesting to display the tool on an open-access website, we require that you only use the sample version of the tool(s)*

I agree to this condition
If you are requesting to use this tool in an Electronic Medical Record (EMR), we require that you submit a screenshot of the tool on your system before you receive the copyright*

I agree to this condition
Please provide us more information about the book
Tentative title of the book*
What edition is this?*
Expected Year of Publication *
Publisher*
Please provide more information about how you will use the tool(s)*
Briefly explain your position in palliative care*
Should be Empty: