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REPLEK FARM

REPORT OF ADVERSE DRUG REACTIONS

Your Health, Our Obligation 

INFORMATION ABOUT THE REPORTER

INFORMATION ABOUT THE PERSON WHO EXPERIENCED THE ADVERSE DRUG REACTION

Gender

ADVERSE DRUG REACTION INFORMATION

INFORMATION ABOUT THE SUSPECTED DRUG THAT CAUSE THE ADVERSE REACTION

Did the reaction withdraw after stopping the drug?

Did the drug previously cause similar reaction?

ADDITIONAL INFORMATION

REPLEK FARM Ltd. Skopje don’t keep any personal information about you. By clicking „I agree“, you agree that we may process your information.

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