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  • Patient Details

  • Suspected Drugs

  • Suspected Reactions

  • Do you consider the adverse reactions to be serious?

  • Other Drugs

  • Did the patient take any other drug in concomitant with the abovementioned product?

    If Yes, please give the following information if known:

  • Additional Relevant Info

  • E.g. medical history, test results, known allergies, suspect drug interactions. For congenital abnormalities please state all other drugs taken during pregnancy and the last menstrual period.

  • Prescribing / Attending Physician

  •  -
  •  -  - Pick a Date
  • Should be Empty:
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