Adverse event notification

INFORMATION ABOUT THE NOTIFICATION

First name of the person making the adverse event notification * :

Last name of the Person Making the Adverse Event notification * :

Address of the person making the adverse event notification :

Occupation * :

Physician

Pharmacist

Dentist

Midwife

Other health member

Non-Healthcare profession

Unknown

* :

Phone number * :

Yes

No

Phone number * :

Can we call you? * :

Yes

No

On which days and in what time intervals can we call you? :

Fax number * :

Yes

No

Fax number :

Can we reach you by fax * :

Yes

No

E-mail address * :

Yes

No

E-posta * :