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    Reporter Information

    First Name* (required)

    Last Name* (required)

    Phone Number* (required)

    Email Address* (required)

    Sex* (required)

    Age* (required)

    Patient/Consumer Information (Who Experienced the Adverse Event)

    To avoid duplicate reports, at least the initials of the first and last name are required.

    First Name* (required)

    Last Name* (required)

    Phone Number* (required)

    Email Address* (required)

    Sex* (required)

    Weight*

    Height

    Pregnant* (required)

    Hospitalized* (required)

    Symptoms experienced after taking the medication* (required)

    Purpose of using the medication* (required)

    Product or Medication

    Brand Name* (required)

    Generic Name* (required)

    Indication / Daily Dose* (required)

    Start Date of Use* (required)

    End Date

    Number of Doses Received

    By clicking “Submit”, I agree to share the personal information provided in this form. For any additional information, you may contact the Drug Regulatory Office (DROMEINTER) at the following phone number: +(504) 9435-2127.