1. Data of the patient who suspects an adverse reaction
Initials or patient name*:


Age:

Gender:WM


2. Suspicious drug
Product Liomont:

Lot number:

Expiration date:

Start date of treatment:



3. Suspected Adverse Drug Reaction
Start date of adverse reaction:

Description of the adverse reaction: *



4. Notifier Data
Name of the person reporting the reaction: *

Phone (LADA): *

Hours available to receive a call-up (if necessary):

Email:



5. Additional comments:

Do you wish to be contacted by Liomont Laboratories Pharmacovigilance staff?
YESNOT

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