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Main / Portfolio / Pharmacovigilance / Questionnaire for medical workers

Reporting form to be sent to the pharmacovigilance service for GEROPHARM medicinal products for medical professionals

Confidential if filled in. You can send the form at any stage of its filling in

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Description of the problem
Patient details
Information about the case
Information about the suspected medicinal product
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Information about the solvent
If a solvent was used for the administration of the suspected medicinal product, please provide the information about it
Information about the concomitant therapy
Please indicate all the drugs you took simultaneously with the suspected medicinal product and during the 3 months that preceded the beginning of the therapy with the suspected medicinal product.
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Actions taken to correct the adverse reaction
Consequences of the adverse reaction
Information about the person reporting the adverse reaction
Additional information
Fields marked with * are obligatory to fill in

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