Keto-Mojo: Clinical Trial / Study & Donation Request

Fields marked “required” must be completed.

Section 1: Contact & Organization Information

First Name (required)

Last Name (required)

Email (required)

Phone Number

Company/Institution Name (required)

Website URL

Country/Region (required)

State/Region

Check if you have a tax exemption certificate

Other State/Region

Section 2: Clinical Trial / Study Details

Formal Title of Trial/Study (required)

ClinicalTrials.gov Listing

Briefly describe the study design and protocol (required)

No. of Clients in Trial/Study (required)

Estimated Participant Recruitment Start Date (required)

Estimated Participant Recruitment End Date (required)

Expected Trial/Study Start Date (required)

Expected Study Completion Date (required)

Will participants be enrolled in cohorts?

Is the trial decentralized or site-based? (required)

Have you allocated a technical/devices budget?

Principal Investigator (Full Name & Title) (required)

Is it feasible for the institution to pay via credit card? (required)

Do you plan to use an application (mobile/web) for data collection?

Which Electronic Health Record (EHR) will be used?

Section 3: Product Donation Request

Have you allocated a technical/devices budget?

If you would like Keto-Mojo to consider providing a donation…

Please provide an itemized list of products requested (quantities, timelines)…

Have you received funding or support for this study?

Has Keto-Mojo previously provided a donation to this institution?

Will you share an anonymized summary of outcomes upon completion?

Will you acknowledge Keto-Mojo’s in-kind support in publications/presentations?

Does Keto-Mojo have permission to reference or feature your study (with approval)?

By submitting, you agree to be contacted regarding this inquiry.

Hubspot Academic Donation Form

Keto-Mojo: Clinical Trial / Study & Donation Request

Section 1: Contact & Organization Information

Section 2: Clinical Trial / Study Details

Section 3: Product Donation Request

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Hubspot Academic Donation Form

Keto-Mojo: Clinical Trial / Study & Donation Request

Section 1: Contact & Organization Information

Section 2: Clinical Trial / Study Details

Section 3: Product Donation Request

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