Ist3gr3.gif (1636 bytes)Thrombolysis in Acute Ischaemic Stroke

Registration Form to Confirm Trial Centre Eligibility

NAME:
DEPT:
HOSPITAL:
STREET:
CITY:
POSTCODE:
 Do you have the following?

Please confirm YES/NO

Instructions
CT scanning or MR

Please indicate which method you would use to send trial CT scans (please tick one box)
EMAIL (ftp,web upload, DICOM send  
CD  
 FILM    

Organised Stroke Service

(e.g. stroke unit or stroke team).

   Please specify
Prepared to develop written local protocols (treatment and nursing) to "fast-track" eligible patients.    
Identified area to administer thrombolysis and monitor the patient   Please specify

 
Do you have a protocol for treating selected stroke patients under 3 hrs with I.V. rt-PA    
If yes, about how many stroke patients did your centre treat with I.V. rt-PA in the past 12 months   Enter number:

________________________________________ (signature of Centre Coordinator) 

Email address__________________________________________________

Please return by fax or post to:

IST-3 Trial Coordinator
Department of Clinical Neurosciences
Bramwell Dott Building
Western General Hospital
Crewe Road
Edinburgh EH4 2XU
UK
Tel: +44(0) 131 537 2793              Fax: +44(0) 131 332 5150