Side effect form

Reporters Data

Name of the reporter*:

Contact email*:

Contact phone number*:

Qualification:

Patient initials, date of birth or age, sex*:

Detailed description of the adverse event/reaction, complaints, additional relevant information*:

Name of the suspect drug(s)*:

Indication(s) for use*:

Dosage:

Date and time of start of drug/medication/therapy:

Date and time of last administration:

List of concomitant drug(s):

I have read , accept and agree to the processing of the personal data provided.

The fields marked with * are mandatory