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Dietary supplements

Pharmacovigilance

Adverse reaction reporting form

Consumer initials*

Specify gender*

Male Female

Age in full years*

Region

Suspected medicinal product information

Product name*

Dosage forms

Manufacturer

Disease for which the product was used (treatment or prevention)

Start date of product use

End date of product use

Date adverse event began

Date adverse event ended

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Reporter information

Reporter full name (Surname, initials)*

Preferred method of contact*

E-mail*

Phone number*

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