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Pharmacovigilance
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Form
Report case RAM
Pharmacov
Patient data
Select document
*
DNI
CE
Passport
Document number
*
Full name
*
Full name
First name
First name
Last name
Last name
Date of birth
*
Phone
*
E-mail
*
Address
Address
Address
Address
City
City
Estate
Estate
Zip code
Zip code
Suspected drug
Product Name
*
Manufacturer
Presentation
*
Batch
*
Dosage
Description of Adverse Drug Reaction (RAM)
Start date
*
End date
*
Severity
*
Mild
Moderate
Severe
Concurrent Medication
Description / Details
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