1. Information about the person that experienced the adverse drug reaction:
In the interest of objective evaluation of your report on suspected adverse reaction, please leave your contact details and you will be immediately contacted by our expert.
Fill in one of the three following data at least (the data will not be associated with the case report above, it is used only for follow up contact of our expert to identify any additional information).
2. Information about the suspect drug (drug which caused an adverse reaction)
3. Information on the progress of the adverse drug reaction: