F01. Institution data entry form
YOU NAVIGATE FROM FIELD TO FIELD WITH THE "TAB" KEY OR WITH MOUSE. DO NOT PRESS THE "ENTER" KEY UNLESS YOU ARE READY TO SUBMIT THE FORM.
mandatory field - mandatory field
M.jpg (998 bytes) 01. Hospital name:
 M.jpg (998 bytes) 02. Department:
M.jpg (998 bytes) 03. Street:
 M.jpg (998 bytes) 04. Street number:
M.jpg (998 bytes) 05. City:
 M.jpg (998 bytes) 06. ZIP or Postal Code:
N.jpg (841 bytes) 07. State:
 M.jpg (998 bytes) 08. Country:
M.jpg (998 bytes) 09. Phone:
 N.jpg (841 bytes) 10. E-mail:
M.jpg (998 bytes) 11. Fax:
 N.jpg (841 bytes) 12. Internet site:
M.jpg (998 bytes) 13. Do you agree to have the name of your center listed
on the website as  participating center?  No Yes
If you opt not to be listed, the name of your center will not appear on screen. Also if there is a need to transfer one of your patients to another surgeon, this will not be possible automaticly. You have however the option to obtain such transfer through email to eurofoetus@eurofoetus.org
M.jpg (998 bytes) This form is secured against improper use.
 Which one of the following products can be used for the induction of anesthesia? Please indicate one correct answer:
Ampicillin Ketamine Meperidine Chloramphenicol
IF YOU WANT TO KEEP THE COMPLETED FORM FOR YOUR RECORDS, PLEASE PRINT IT BEFORE SUBMITTING
EUROFOETUS telephone : xx-32-496-23.99.92
Please call this number only in case of urgent problems. For all other problems or questions, we ask you to use e-mail to eurofoetus@eurofoetus.org