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For consumers of a medicinal product
For the consumer of the medicinal product
Data on a person reporting information on the development of an undesirable reaction
Name or initials
*
Phone number
*
Who the patient is
*
Your E-mail
Patient Information
Full name
*
Sex
*
Phone number
*
Country
*
Age
*
Information about the suspected drug
The trade name of the medicinal product you used
*
For what purpose did the said medicament
*
Date of beginning of use of the medicinal product
*
Serial No. (see packaging)
*
How the drug was taken
*
End date of use of the medicinal product
*
Information on undesired reaction / lack of effectiveness
Description of the case of adverse reaction / lack of effectiveness
*
Form submission date
*
Date of onset of unwanted reaction
*
Fields with
*
is required.
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