
	F02. Surgeon 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


	01.	Last Name:		02.	Middle Name:
	03.	First Name:
	04.	center: If your center is not listed, go first to 'New center Form'.
	05.	Office phone:		06.	E-mail:
	07.	Office fax:		08.	Internet site:

	09.	Participation in the studies is possible through the following means: Please indicate your choice. Please check one box only. Via the internet (preferred choice) With manualy filled out Clinical Record File forms On floppy disks (MS Access 97®) (not yet available) When the option 'With manualy filled out Clinical Record File forms' is chosen, please send these forms via postal mail to : Eurofoetus, c/o Dr. Jan Deprest, Dept. of Obstetrics and Gynaecology, UZ Leuven, B-3000 Leuven, Belgium, or fax at his attention to number xx-32-16-34.42.05. Please keep a copy for your records.

		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