PHARMACOVIGILANCE FEEDBACK FORM FOR CONSUMERS

*fields with an asterisk are mandatory

1. Report of a suspected ADR or LOE of a drug

Full name^*

Country^*

Date of birth^*

Gender^*

Phone^*

2. Information about the suspected drug

Date of first contact with the manufacturer

Trade name of the drug that you have taken (see packaging)*^*

Batch number (see packaging)

Expiration date

Brief description of the issue or defect, including information about adverse reaction/lack of efficacy, quality defect

Where the drug was purchased

Drug sale date

Unpacking date

Attach files

Maximum number of files - 10. Maximum file size - 10Mb.Acceptable extensions:(*.jpg,*.gif,*.png,*.doc,*.docx,*.xls,*.xlsx,*.pdf)

3. Information regarding the company’s privacy policy

Consent to the collection, processing, storage and use of personal data^*

Consent to the company’s privacy policy^*

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