Report an adverse event

Detailed form for healthcare professionals

Your information (Reporter)

Email *

Phone *

PIN Code (6 digits) *

To track your report.

Initials *

Gender *

Age *

Weight (kg)

Height (cm)

Date of Birth

Medical history

Known allergies

Medication Name *

Generic Name

Strength *

Pharmaceutical form

Laboratory

Marketing Authorization Number

Start Date

End date

Posology

Expiration date

Indication

Title of the effect *

Event Description *

Start Date *

Severity *

Outcome

Actions Taken

Drug withdrawn Dose Reduced Symptomatic Treatment Hospitalization

Additional Comments