Side effect report for health proffesionals (physicans, pharmacists)

Short name of the medicinal product*

Strenght of the product*

Lot number (as indicated on the box)*

Name or initials of the patient suffering from the below detailed side effect*

Name of the health professional*

Employer of the health professional*

Addresse*

E-mail*

Phone number*

Detailed discription of the side effect, symptoms, observations*

* mandatory fields