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PV Case

PV Case

PV Hotline number: 22276873

DATE OF CONTACT :
IDENTIFICATION OF THE REPORTER:
Surname:
Firstname:
Region:
Phone No.:
INFORAMTION ABOUT THE PRODUCT :
Name
Dosage Form:
Route of Administration:
Batch No.:
Expiry Date:
Company Name:
IDENTIFICATION OF THE HEALTHCARE PROFESSIONAL:
Surname:
First Name:
Dosage Form:
Specialty:
Phone No.:
Professional Address (if hospital, precise the service):
IDENTIFICATION OF THE REPORTER:
First Name:
Gender:
Weight:
Age of concerned patient:  
Therapy Date (From/to )
Therapy Duration:
Date of reaction onset:
Patient's Medical History including pre-existing conditions: (ex: Diagnostic, allergies, pregnancy with last month of period etc .... ):
Concomitant Drug & Dates of Administration:
SUSPECTED ADVERSE REACTION REPORT AND PARTICULAR SITUATIONS
(EXPOSURE DURING PREGNANCY AND LACTATION, MISUSE, DRUG ABUSE, OVERDOSAGE. DRUG DEPENDENCE, MEDICATION ERRORS, LACK OF EFFICACY, SUSPICION OF TRANSMISSION OF INFECTIOUS AGENTS, ADVERSE EFFECT LINKED WITH A PRODUCT QUALITY COMPLAINT)
Reported effect(s) or particular situation(s) (description using the reporter's terms):
Corrective Treatment.

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PV Hotline number: 22276873

 

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