<! DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0//EN">
<HTML>
<TITLE> Centrul de Informaţie despre Medicamente. Agenţia Medicamentului </TITLE>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1251">
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<meta name="keywords" content="Agenţia Medicamentului, informaţie, medicina, farmacia, medicamentul, controlul, autorizarea, Агентство по лекарствам">

<STYLE>
body {font-family: Times;
     }
A {text=decoration:none; color: green; font-weight: bold;}
A:link {text=decoration:none; color: green; font-weight: bold;}
A:visited {text=decoration:none; color: green; font-weight: bold;}
A:hover {color:red;}

        .f2 {border: 1px solid navy;
            background-color: white;
            color: navy;}
</STYLE>


<BODY style="background-image:url('images2/fon5.bmp'); background-repeat: repeat;" 
	LEFTMARGIN="0" TOPMARGIN="2" MARGINWIDTH="0" MARGINHEIGHT="0" >

<TABLE align=center style="border: 0px solid navy;" width="760" cellpadding="0" cellspacing="0" >

  <TR> 
<td colspan=2 weight=760 height=100 align=right valign=bottom 
		style="background-image:url('titlu_cim_v1.gif');
	       	background-repeat: no-repeat;color: red;"> 
		
&nbsp;
</td>
  </TR>
</TABLE>

<TABLE align=center style="border: 0px solid navy;" width="770" cellpadding="0" cellspacing="0" >

  <TR>

<TD width='175px' height=210 valign='top' align='center' style="border: 1px;  padding: 3px; font-weight: bold;">

<table cellpadding="0" cellspacing="0" width="175" height=267 valign=top style="background-image:url('fon2_meniu.gif'); font-size:14px; font-weight: bold; border: 1px solid green;">

<tr >
  <td height='35'> &nbsp;<img src=images2/arrow.gif>  <a href="cim.am.html" style="text-decoration:none;"> &nbsp;Prezentare  </a> </td>
</tr>

<tr >
  <td height='35'> &nbsp;<img src=images2/arrow.gif> <a href="cim.ancheta.html" style="text-decoration:none;"> &nbsp;Adresează o întrebare </a> </td>
</tr>


<tr >
  <td height='35'> &nbsp;<img src=images2/arrow.gif>  <a href="cim.tel.html" style="text-decoration:none; "> &nbsp;Contact</a> </td>
</tr>

<tr >
  <td height='92'> &nbsp; </td>
</tr>


</table>

<table>
<tr> 
<td align=center> <br><br><br>
<a href="http://www.usaid.gov/" target="_blank"><img src='usaid.gif' border="0"></a>
</td>
</tr>
<tr> 
<td align=center> 
<a href="http://www.usp.org/" target="_blank"><img src='usp.gif' border="0">
</td>
</tr>
</table>
</TD>

<TD align=center style='padding: 3px;'>

<table style="width: 578px; border: 1px solid green; font-size: 11px; background-color: white;" cellpadding="3" >
<tr>
<td colspan=2 align="left" style="font-size: 13px; width: 580px; height: 30px;"><B>&nbsp;Adresează o întrebare</B></td>
</tr>

<tr>
<td colspan=2 align="left" style="font-size: 12px; color: green;  width: 580px; height: 30px;"><B>&nbsp;Adresaţi-ne întrebările dumneavoastră On-line</B><br>
<font color=black > &nbsp; * ) - Completarea cîmpurilor este obligatorie <br>
 			 ** ) - Completaţi cel puţin una dintre informaţiile de contact.</td>
</tr>


<tr> <td style='font-size: 11px;'>
<br><br>
<Form Action="mailto:cim@amed.md" Method="POST" Enctype="text/plain" Name="mail">
<Table Border="0" style='font-size: 13px;'>
<Tr><Td Align="Right" Valign="Top">Numele dumneavoastră*:</Td>
<Td ><input type="text" name="Nume" value="" size="25" ></Td></Tr>
		  <tr>
		  	<td align="right" >Funcţia/specialitatea*:</td>
		  	<td>
			<select name="Functia" >
			  <option value="Asistent medical" >Asistent medical	</option>
			  <option value="Farmacist" >Farmacist 		</option>
			  <option value="Farmacist rezident" >Farmacist rezident	</option>
			  <option value="Farmacist laborant" >Farmacist laborant	</option>
			  <option value="Farmacolog" >Farmacolog		</option>
			  <option value="Medic" >Medic		</option>
			  <option value="Medic de familie" >Medic de familie	</option>
			  <option value="Medic specialist" >Medic specialist	</option>
			  <option value="Medic rezident" >Medic rezident	</option>
			  <option value="Medic laborant">Medic laborant	</option>
 			  <option value="Pacient">Pacient		</option>
			  <option value="Student">Student		</option>
			  <option value="Alta">Alta		</option>
			</select>
			</td>
		  </tr>
		  <tr>
		  	<td align="right" >Instituţia*:</td>
		  	<td><input type="text" name="Institutia" value="" size="25" ></td>
		  </tr>
		  <tr>
		  	<td align="right" >Adresa instituţiei*:</td>
		  	<td><input type="text" name="Adresa" value="" size="25"></td>
		  </tr>
		  <tr>
		  	<td align="right" >Telefon**:</td>
		  	<td><input type="text" name="Telefon" value="" size="25" ></td>
		  </tr>
		  <tr>
		  	<td align="right" >Fax**:</td>
		  	<td><input type="text" name="Fax" value="" size="25" ></td>
		  </tr>
		  <tr>
		  	<td align="right" >E-mail**:</td>
		  	<td><input type="text" name="Email" Value="" size="25" ></td>
		  </tr>
		  <tr>
		  	<td align="right" valign="top">Termen limită pentru răspuns*:</td>
		  	<td><input type="text" name="Termen" value="" size="25" ><div class="gFormComment">Format: ZZ/LL/AAAA</div></td>
		  </tr>
		  <tr>
			<td> <b>Informaţie despre pacient:</b></td>
                  </tr>	
		  <tr>
		  	<td align="right" >Sexul:</td>
		  	<td >
				<input type="radio" name="Sex" value="masculin" >&nbsp;Masculin
				<input type="radio" name="Sex" value="feminin" >&nbsp;Feminin
			</td>
		  </tr>
		  <tr>
		  	<td align="right">Vîrsta:</td>
		  	<td><input type="text" name='Virsta' value="" size="25" ></td>
		  </tr>
		  <tr>
		  	<td align="right" >Greutatea:</td>
		  	<td><input type="text" name='Greutate' value="" size="25"></td>
		  </tr>
		  <tr>
		  	<td align="right" valign="top">Medicaţie curentă:</td>
		  	<td><textarea cols="40" name='Medicatie' value="" rows="5"></textarea></td>
		  </tr>
		  <tr>
		  	<td align="right" valign="top">Alergii cunoscute:</td>
		  	<td><textarea cols="40" name='Alergii' value="" rows="5"></textarea></td>
		  </tr>
		  <tr>
		  	<td align="right" valign="top">Întrebarea adresată*:</td>
		  	<td><textarea cols="40" name='Intrebare' value="" rows="7" Wrap="virtual"></textarea></td>
		  </tr>
		  <tr>
		  	<td align="right">&nbsp;</td>
		  	<td align=center> <input type="submit" size="15" value="Trimite întrebarea">&nbsp;<input type="reset" value="Renunţă"></td>
		  </tr>
		</form>
</table>
</td> 
</tr>

</table>

<img src="fon5_2.gif" align=center border=0> 
</TD>

</TR>
</TABLE>

<TABLE align=center width="760" cellpadding="8" cellspacing="0" style="background-image:url('cim_c.gif'); border: 1px solid green;" >
<tr> 
<td align=center>
<!-- Start | SUPER.MD v2 | ID#4660 -->
<SCRIPT language=JavaScript>
<!--//
st="<A HREF='http://super.md/' TARGET='_top'><img src='http://v1.super.md/?col=00996600;b=a;id=4660;v=2;je=";
st+=((navigator.javaEnabled()==true)?"y":"n");
st+=";pp="+escape(document.referrer)+";cp="+escape(window.location.href);
st+=";sh="+screen.height+";sw="+screen.width+";sc="+screen.colorDepth;
st+="' border='0' alt='super.md'></A>"; document.write(st); //--></SCRIPT>
<NOSCRIPT>
<A HREF="http://super.md/" TARGET="_top"><IMG SRC="http://v1.super.md/?col=00996600;b=a;id=4660;v=2;je=0" alt="super.md"></A>
</NOSCRIPT>
<!-- End | SUPER.MD v2 | ID# -->

</td>
<td align=center style="font-size: 12px; "> <b>Coordonatele CIM: </b><br>
 Centrul de Informaţie despre Medicamente (CIM), Agenţia Medicamentului <br>
 MD-2028 Chişinău, str. Korolenko nr. 2/1, biroul 21 <br>
 Tel/fax: 022 727174, e-mail: <a href="mailto:cim@amed.md" style="color: red;">cim@amed.md</a>
</td>
</tr> 

</TABLE>

</body>

</html�