Pharmacovigilance Reporting

Who is reporting?*

Your first name:*

Your last name:*

Your email address:*

Your telephone number:*

Your address:*

Patient age in years:*

Patient date of birth:

Patient gender at birth:

Name of product (name, strength and pharmaceutical form)*

Details of issue (side effect/product quality)*

What was the product prescribed for?

Product licence number:

Product batch number:

Batch expiry date:

Has this already been reported to the HPRA?*