Home K Meldung einer Nebenwirkung Reporting an adverse reaction Affected person/patient Title Title Ms./Mrs. Mr. Other First name Last name Date of birth Street no. Postcode City Country Phone E-Mail Are you affected yourself, or are you reporting on behalf of another person? Are you affected yourself, or are you reporting on behalf of another person? Affected person Notifying person Meldende Person Title Title Ms./Mrs. Mr. Other First name Last name Phone E-Mail Information about the product Name of the product Instillagel®InstillaGel Lubri®Endosgel®Instillaquill®FARCO-PenisklemmemediNik®VESOXX®Ialuril® PrefillFarco fill® Aqua GlycerolDeflux® What is the batch/ serial number (serial no./lot no.) of the product used? Why was the product used? Have you used or taken any other medication? Have you used or taken any other medication? Yes No Wenn ja, welche? Side effects How was the product applied, and how much was used? What adverse effect has occurred? What countermeasures have been taken? Who else was notified besides FARCO-PHARMA? Doctor involved Title Title Ms./Mrs. Mr. Other Last name Street no. Postcode City Phone E-Mail Data protection Data protection I have read the privacy policy. I consent to the collection and digital storage of my details and data to answer my inquiry. Note: You can revoke your consent at any time in the future by sending an email to [email protected]. Send
