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Fill out the form below:

1. Patient information:

Full name*

Address

Теl./fax*

E-mail

2. Suspected medicinal product information

Trade name*

Dosage form*

Manufacturer

3. Suspected medicinal product prescription information:

Suspected medicinal product was prescribed to the patient by a doctor:
yes no 

Patient used a suspected medicinal product without a doctor’s prescription:
yes no 

4. Adverse reaction description or lack of efficacy indication*

5. Information about the notifier

Full name

Location

Теl./fax

E-mail*

6. Information about the doctor and health care institution in the place of residence of the patient who has suffered an adverse reaction or lack of efficacy

Full name

Health care institution location

Теl./fax*