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Pharmacovigilance
Online Report
1- Data of the person reporting the event
Reported by:
Select
Health professional
Patient
Other
Name and surname
Specialty (If applicable)
Phone
Email
2- Patient data
Name and Surname (Initials)
Gender
Select
Male
Female
Other
Date of birth
Age
Weight
Height (cm)
3- Drug suspected of adverse event
Drug name / Presentation
Dose
route of administration
Lot Number
Maker
Due date
4- Detailed description of the adverse event that occurred
Please include all detailed information about the event: start date, if you took any other medication or the like to recover, completion date, and any additional information you can describe about the event.
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