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CASE REPORT ON ADVERSE REACTION ( AR) OR LACK OF EFFICACY ( LE)
  1. INFORMATION ABOUT PATIENT
  2. Initials:
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  3. Country:
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  4. Date of birth:

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  5. Age (years):
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  6. Gender :
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  7. INFORMATION ABOUT AR/LE
  8. AE Category:
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  9. Date of report:
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  10. Description of AE
  11. Invalid Input
  12. Onset of AE:

    Invalid Input
  13. And of AE:

    Invalid Input
  14. INFORMATION ABOUT SUSPECTED MEDICINAL PRODUCT (SMP)
  15. SMP (trade name, dosage form):
    Invalid Input
  16. Single dose and dose frequency:
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  17. Indication for prescription:
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  18. Therapy date From:

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  19. Therapy date To:

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  20. INFORMATION ABOUT SOURCE:
  21. Initials:
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  22. Status:
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  23. Address:
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  24. Phone/Fax:
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  25. E-mail:(*)
    Invalid e-mail address
  26. Enter the verification code from the right in the picture:
    Enter the verification code from the right in the picture:
    Invalid Input
  27. (*) – requiered fields
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