Form for the consumer

A REPORT OF A SUSPECTED SIDE REACTION OR LACK OF EFFECTIVENESS OF THE DRUG

Full name

Country

Age

Sex
malefemale

e-mail

INFORMATION ABOUT SUSPECTED DRUG

Trade name of the medicinal product that you used (see packaging)

Series № (see packaging)

INFORMATION ABOUT SIDE REACTION/LACK OF EFFECTIVENESS

Description of the case of side reaction / lack of effectiveness