Notification of adverse events

Person reporting event

profession:
Input profession:
First name:
Last name:
E-mail:
Phone:

Patient information

Gender:
date of birth:
Age of the patient:
Patient's initials:
Race:
Time frames:
Medicinal product used since:
Dose:
Route of administration:
orally
intramuscular injection
intravenous injection
Other, concomitant medicinal products:
(name, dose, frequency)

Drug information

Name of medicinal product:
Lot number:
Description of the event:

The information provided in this form are not stored in any way and will not be used any purpose other than the execution of the service.

I agree to the use of the information provided by me in the above form only to execute this service. At the same time I declare that I have read the rules of service and fully accept its provisions.