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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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