Clinical Toxicology/Poison Centre Outbreak Report Form

Please complete this form if you have an oubreak of clinical interest that you would like to highlight to EAPCCT members.

EAPCCT: Clinical Toxicology / Poisons Centre Outbreak Report Form

Name(Required)

First Last

Email (This email address will not be shared publicly)(Required)

Poison centre or organization reporting the outbreak(Required)

Email of the centre/organization reporting the outbreak (This email address may be shared publicly)(Required)

Outbreak(Required)

Please describe the outbreak in 3-4 sentences:

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