Form of notification - Nobel AFF

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Form of notification

Consumer
Employee medical sphere

Form of notification

Full Name:*

Contact number:*

Age:

Gender:

male

female

Enter your e-mail

The trade name of the medicinal product you used (see packaging):*

Series No. (see packaging):

Description of the case of adverse reaction / lack of effectiveness:*

Form of notification

Full Name:*

Contact number:*

Professional affiliations:

Enter your e-mail

Patient initials:*

Age:

Gender:

male

female

The trade name of the medicinal product you used (see packaging):*

Series No. (see packaging):

Description of the case of adverse reaction / lack of effectiveness:*

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