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* Sex:
* Age or date of birth:
* Contact details of the patient or the applicant (phone / email / address):
* Drug allegedly caused undesirable:
* Serial number:
* Tick ​​if an adverse event associated with one of the below-described situations:

* Describe adverse, from a medical point of view, the event (side effects, adverse reactions, ...), which caused the use of the drug:
* Captcha:
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