Pharmavigilance
Tipology
select the tipology
Name and Surname*
Address*
Contact and ASL authority*
Name and Surname*
Address*
Contact and Competent Pharmacy*
Institution name*
Address*
Contact*
Initials of Name and Surname*
Gender
Specify more*
Address*
Contact*
Report reason*
(provide a brief description of the event that gave rise to the report, taking care to also report the sex and age of the interested party)
Declaration of consent*
Privacy Policy*
Correct the form fields and retry