OBSTETRICS & PERIO THERAPY STUDY
Receipt of Subject Payment Gift Certificates/Cards
This form must be completed upon receipt of monthly gift certificates/cards used for subject payments. When
completed, please fax the form to the OPT Study Administrative Center at 612-626-3938.
Date of Receipt: - -
Month Day Year
Total number of Certificates/Cheques Received:
Number of Certificates Received for:
Upon receipt of the gift certificates/cards from the OPT Study Administrative Center, this clinical site accepts
full responsibility for the proper handling, security and distribution of the certificates/cards and acknowledges
financial responsibility for any loss or theft of these items.
Name of Person Completing Form (Print):
Signature of Person Completing Form:
Once this form is completed, FAX a copy immediately to the Administrative Center at 612-626-3938.
OPT Form 101 V1 (1-1) MAR 03