Pharmavigilance
Type
select type
First name and last name*
Address*
Contact and Competent Local Health Authority*
First name and last name*
Address*
Contact and Competent Pharmacy*
Entity name*
Address*
Contact*
Initials of Name and Surname*
Gender
Specify other*
Address*
Contact*
Reason for reporting*
(provide a brief description of the event that prompted the report, taking care to also report the gender and age of the subject involved)
Declaration of consent*
Privacy Policy*
Correct the form fields and retry