Pharmacovigilance Adverse Reaction Reporting Form Current PATIENT REPORTER / PRIMARY SOURCE SUSPECTED MEDICINE SUSPECTED ADVERSE DRUG REACTION (ADR) Send Complete Age Use format years/months Date of birth Date of birth: Date Date of birth: Time Weigh (only if pediatric patient) Specify in kg Sex - Select - Male Female ADR Reporting Form Guide Other means of communication Contacting Diater directly:farmacovigilancia@diater.com+34 914 96 60 13 Through your doctor, pharmacist, nurse, etc.
