Message about an adverse effect of a medical product

Information about the reporter

Full Name *

Place of employment, position *

Address *

Contact telephone number *

Fax

E-mail *

Information about the patient

Full Name *

Age, sex, weight, height *

Contacts *

Information about the medical product

Name *

Manufacturer *

Series number *

Expiry date *

Number of packages available from the reporter *

Where the medical product was purchased *

What were the storage conditions before use *

Форма поиска