Pharmacovigilance report

The boxes marked with an asterisk * are necessary to follow up on your request. We will contact you by e-mail or phone to assist you.

* Name (may be initials):

* Last name (may be initials):

* Gender (indicate male or female):

* Country, State or City:

* Phone Number with long distance dialing code. Example: 55 5482 9000

E-mail address:

* Suspicious medication (please indicate the active substance or brand):

Start date of the event (dd,mm,yy):

* Explain in detail the suspicion of adverse reaction / side effect / symptom / discomfort presented / quality complaint:

* Security check:

I want to be contacted by Apotex, to follow up on my pharmacovigilance report.

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