Payment Details "*" indicates required fields Participant Name* First Last Participant ID* Study* AGEART - $100 ALVCIR - Select timepoint/s below BAVBIO - $100 BIOCAR - $200 CAPSTA - Select timepoint/s below CELCAR - $50 FENCOV - $250 GOBO - Select timepoint/s below GLP1PK - $700 GRYAGE - $200 GRYAGE - $200 GIFT VOUCHER IHATID - $150 KURTIS - $300 LEVESS - Select timepoint/s below MAOGIT $300 MAOJOI - $350 MAOJOI Part B - $250 PEPSLE - Select milestone below PETLEV - $150 PLXCOM Quercetin - $600 PROPAL - $200 PROSLE - Select timepoint/s below TESTEF - $150 PROSLE Time Point Screening $50 First PK $200 Second PK $250 ALVCIR Failed Blood Pressure Screen $30 Week 1 Clinic Appointment $55 Week 4 Clinic Appointment $55 Week 8 Clinic Appointment $55 Week 11 Clinic Appointment $85 CAPSTA All study obligations met (pay $2790 total) Blood Sample SNP $80 In Clinic Medical Screening $80 Buccal Sample 1 $375 PK Full day in clinic $200 Daily follow up visits $880 ($80x11) Daily compliance log (home) $300 ($30x10) Buccal sample 2 $375 Study Completion $500 Other amount (see below) LEVESS Medical Screening appointment $50 Baseline Clinic Appointment $80 Month 3 Clinic Appointment $80 Month 6 Clinic Appointment $80 Month 9 Clinic Appointment $80 Month 12 Clinic Appointment $130 PEPSLE Milestones reachedPlease check all that apply Day 0 - Failed OURA screening, returned ring $50 Day 28 - $50 Day 57- Study Complete $100 ($200 total payment) HiddenCERTOL Payment stages Screening Appointment $50 Day 1 Clinic Dose $100 Day 2-4 $50 Day 5-6 $50 Day 7-8 $50 Day 9 PK Morning Dose $250 Day 9 PK Afternoon Dose $450 (Group 1&2 only) Day 9 PK Afternoon Dose $250 (Group 3 only) Day 9 PK Evening Dose $450 (Group 3 only) Day 10-12 $50 Day 13-14 $50 Day 14-15 $50 Day 16-17 $50 Day 18-20 $50 Final SNP Blood Draw $100 Day 21 PK Morning Dose $450 (Group 1&2 only) Day 21 PK Morning Dose $250 (Group 3 only) Day 21 PK Afternoon Dose $700 (Group 1&2 only) Day 21 PK Afternoon Dose $450 (Group 3 only) Day 21 PK Afternoon Dose $700 (Group 3 only) If other amount ..please provide detail Full Stipend to be paid?* Yes No If not full amount, please enter the TOTAL amount to be paid. Account Name* BSB* Account Number* Authorised by:*Enter Trial Coordinator Name
