Adverse Events

Are you a patient or a rapporteur?*

Rapporteur's full name*

Are you a health professional?

Yes No

What is your profession?*

product used

Product identification*

Other product*

period of use

When did you start using the product?

Unknown

When did you stop using the product?

Unknown

In progress

reasons and conditions of use

For what reason or condition are you using the Biolab product?

Unknown

product information

Lot number

Unknown

Product expiry date

Unknown

Dosage

Product images

Take a photo of the product where the batch/lot number appears

If necessary, you can upload up to 3 files of 2 MB each.

Drag and drop the files here

Symptoms

What symptoms occurred?*

period

When did your symptoms start?

Unknown

When did your symptoms stop?

Unknown

In progress

consequences of symptoms

Have the symptoms been treated?

Yes No

Describe how the treatment went

current status

The symptoms resulted in:

Fully recovered Recovering I can't say

Is there any other information you'd like to share, including any relevant medical history?

Patient data

Patient's full name

Age

Gender at birth

Is the patient pregnant?

Yes No I don't know

contact

Will you allow us to contact you if necessary?

Yes No

E-mail:

Phone: