REPORT ADVERSE EVENT

If you want to report an adverse event, any signs, different or unexpected symptoms from the therapeutic benefit of the drug, you can inform us using the following form or by calling +502 3023-1246. It is advised not to share personal information that is not specific to the adverse event to achieve a clear communication.

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PATIENT DATA

Names or Initials*

Age

Sex

MEDICATION DATA

Product*

Batch

NOTIFIER DATA

Descripción*

Datos del notificador

Contact Name

Phone Number

Email Address

I agree that Asofarma staff can contact me*

Yes

Comments

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