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Adverse drug reaction form for consumers
Patient Information
Full name
Please type name.
Address
Please type adress.
Phone
Invalid phone number
E-mail
Invalid email address.
Information on a suspected medicinal product
Trade name
Please fill the form
Pharmaceutical form
Please fill the form
Manufacturer
Please fill the form
Information on the administered medicinal product
Was the suspected medicinal product administered by a doctor?
Yes
No
Please select Yes or No
Description of adverse reaction or inefficacy of a medicinal product
Description
Invalid Input
Reporter information
Full name
Please type your name.
Address
Please type your adress.
Phone
Invalid phone number
E-mail
Invalid email address.
Information about a doctor and health care facility at the place of residence of the patient who had an adverse reaction or experienced lack of efficacy of a medicinal product
Full name
Please type name.
Address
Please type address
Phone
Invalid phone number
Additional Information
Invalid Input
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“We Act to Save Lives”
Mistral Capital Management Limited
“We Act to Save Lives”
Mistral Capital Management Limited
Home
About Us
Products
Quality
Pharmacovigilance
Partnership
News
Contact Us