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Strana 2 od 3 [TUE]
3.
Detalji o lijeku / Medication details
Zabranjene supstance: Generički naziv
Prohibited substance(s): Generic name
Doza
Dosage
Način unosa
Route
Učestalost
Frequency
Trajanje terapije
Duration of treatment
1.
2.
3.
4.
Izjava ljekara / Medical practitioner's declaration
Potvrđujem da je su gore navedeni podaci u rubrici 2 i 3 tačni, i da je gore spomenuta terapija medicinski odgovarajuća.
I certify that the information at sections 2 and 3 above is accurate,and that the above -mentioned treatment is medically appropriate.
Ime i prezime:
Name:
Specijalnost:
Medical specialty:
Adresa:
Address:
Telefon:
Phone:
Faks:
Fax:
E-mail:
Potpis ljekara:
Datum:
Signature of Medical Practitioner:
Date:
5.
Retroaktivne prijave / Retroactive applications
Da li je u pitanju retroaktivan zahtjev?
Da
Ne
Is this a retroactive application?
Yes
No
Ukoliko jeste, kojeg datuma je započeto liječenje?
If yes, on what date was treatment started?
Molimo navedite razlog:
Please indicate reason:
Bio je potreban hitan tretman ili tretman akutnog medicinskog stanja
Emergency treatment or treatment of an acute medical condition was necessary
U skladu sa drugim izuzetnim okolnostima, nije bilo dovoljno vremena ili prilike za podnošenje zahtjeva prije
davanja uzorka
Due to other exceptional circumstances, there was insufficient time or opportunity to submit an application prior to
sample collection
Nije bilo potrebno podnositi zahtjev unaprijed, prema pravilima prijavljivanja
Advance application not required under applicable rules
Drugi razlog
Other
Molimo objasnite
Please explain