Report a side effect Name Email address Phone numberDo you work in the health sector? Yes No Can Navamedic contact you? Yes No Have you experienced/seen the side effects yourself? Yes No Who experienced the side effect? I Someone else Gender of the person experiencing the side effect Male Female Unknown Age of the person experiencing the side effect Suspected medicinal product that caused the side effect Describe the side effectDisease or symptom treated with the medicinal product Which dose was used? Indicate start date of the treatment Indicate end date of the treatment or if it is ongoing When did the side effect/symptoms start? Have the symptoms changed? (Remaining/disappeared/improved) Has any other medicinal products/products been used in the same period? Information regarding other diseases Do you authorize us to contact your doctor for a medical assessment? Yes No The form is protected by reCAPTCHA Share on:
