Skip to main content

Pharmacovigilance

    Notifying person

    Patient identification

    Prescribing doctor

    Suspect medicinal products

    Start date

    End daten

    (Format dd/mm/yyyy)

    Adverse reaction

    Start date

    (Format dd/mm/yyyy)

    End date

    (Format dd/mm/yyyy)

    Comments

    Annex

    If you wish, you may attach an image or file below:

    Max. 2 Mb

      Patient identification

      Está embarazada:

      Professional notifying

      Suspect medicinal products

      Start date

      End daten

      (Format dd/mm/yyyy)

      Adverse reaction

      Start date

      (Format dd/mm/yyyy)

      End date

      (Format dd/mm/yyyy)

      Comments

      Annex

      If you wish, you may attach an image or file below:

      Max. 2 Mb