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Adverse Drug Reaction
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Notification of an Adverse Reaction to a veterinary medicinal product
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Name
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Email
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Subject
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Message
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Reporter
Reporting Person
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Veterinarian
Animal owner
Distributor
Other
Adress
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Phone
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Who is affected?
Affected Individuum
*
Animal
Human
Environment
Food products
Animal species
*
If animal is affected
Gender
*
Age
Body weight (estimated)
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Affected Veterinary Medicinal Product
Name
*
Strength
*
Batch
*
Expiry Date
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Adverse reaction
Description of the treatment and the adverse reaction
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