Report AE Use the contact form below to report an adverse event Name * First Last Contact details (phone, address) * SEX Male Female Position and place of work Name of the PATIENT * First Last Contact details (phone, address) * SEX Male Female Short description of the disease * Describe the risk factors: e.g. urinary impairment, use of suspected product in the past, allergies, drug abuse and etc. Medicinal product information - Trade name * INN Batch number * Manufacturer * Composition Dosage, administration method * Description of the situation/ adverse event/complaint disease * Nature, characteristics, localisation, severity, tests results, time of occurence, date when resolved, treatment of AE and outcome. Beginning/End of therapy Additional information if any Date
