Information of the person filing the report:

Name (required)

Surname (required)

Phone number

Email (required)

Patient's information:

Initials (required)

Gender (required)
ManWoman

Name of the medication

Name of the medication (required)

Presentation (required)

Lot

Indication

Dosage

Treatment start date

Description of suspected adverse reaction (malaise) (requerido)

Start date of suspected adverse reaction (malaise):

Have you stopped treatment?:
YesNo

Comments:

I have read the complete Privacy Notice that can be found at the following link, and I agree to provide the requested personal data, and agree with the handling of such personal data.