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Contact - Product safety
Contact - Product safety
Reporter’s information
First name*
Last name*
Email*
Phone*
Reporter details*
Reporter details*
Hospital
Patient's details
Patient initials*
Date of birth*
Age* (Years)
Gender*
Gender*
Suspected product*
Suspected product*
Treatment Date*
Dose*
Indication*
Adverse reaction description*
Reaction start date*
Reaction end date*
Outcome of the reaction*
Outcome of the reaction*
I have read and agreed to the terms of use.*
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