Adverse event report | Izvarino Pharma

If you, when using any of the preparations manufactured by Izvarino Pharma, have encountered an undesirable phenomenon that is not described in the “Side Effects” section of the instructions, or you have complaints about the quality, let us know by filling out the appropriate form.

Adverse event report

Quality questionnaire

Patient name

required field

Patient age

required field

Patient sex

required field

Male

Female

Product

required field

Product batch

required field

Manufacturer

Disease

required field

The start date of taking the drug

required field

The end date of taking the drug

Adverse event start date

required field

Adverse event end date

Adverse event

required field

Sender category

required field

Sender's name

Communication method

required field

Attach file

required field

By clicking the "Send" button, I confirm my legal capacity and consent to the processing of my personal data in accordance with the Privacy Policy.

required field