ADVERSE DRUG REACTION (ADR) REPORTING FORM

Please complete this form to report any adverse drug reactions observed with the use of Magnalabs products or distributed by Magnalabs.

Fields marked with an asterisk (*) are required. Please provide as much information as possible for the message to be evaluated correctly.

After submission, the form is sent to: pv@magnalabs.com, drugsafety@avpharm.com.

 

I. ДАННИ ЗА СЪОБЩИТЕЛЯ

II. ДАННИ ЗА ПАЦИЕНТА

Пол: *

III. ДАННИ ЗА ПОДОЗИРАНОТО ЛЕКАРСТВО

IV. ДАННИ ЗА ПОДОЗИРАНАТА НЕЖЕЛАНА ЛЕКАРСТВЕНА РЕАКЦИЯ