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?
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

  

“We Act to Save Lives”

Mistral Capital Management Limited

“We Act to Save Lives”

Mistral Capital Management Limited