Side effect report for patient and/or their relatives

Short name of the medicinal product*

Strenght of the product*

Lot number (as indicated on the box)*

Do you take other medication?*

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

Name of the person reporting the side effect*

Addresse of the person reporting the side effect*

E-mail*

Phone number*

Detailed discription of the side effect, symptoms, observations

* mandatory fields